Citation Nr: 1602351 Decision Date: 01/20/16 Archive Date: 01/27/16 DOCKET NO. 08-31 442 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for a right foot disability. REPRESENTATION Veteran represented by: The American Legion WITNESSES AT HEARING ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD Journet Shaw, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1964 to July 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions in September 2007 and February 2008 by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran and his wife testified before the undersigned Veterans Law Judge at a July 2010 Travel Board hearing. A transcript of this hearing is of record. In December 2010, the Board previously remanded the issues on appeal for additional development. As the development was not completed, the Board remanded the issues again in May 2015 to comply with the Board's remand directives. The case has been returned to the Board for appellate review. In December 2015, the Veteran submitted additional evidence in support of his appeal. The Veteran had submitted a signed October 2015 waiver of RO consideration of additional evidence submitted since his most recent supplemental statement of the case. The Board accepts this evidence for inclusion in the record. See 38 C.F.R. § 20.1304 (2015). FINDINGS OF FACT 1. The preponderance of the competent and credible evidence does not demonstrate that the Veteran's currently diagnosed bilateral sensorineural hearing loss had its onset during active duty service, manifested within one year of separation, or is otherwise etiologically related to service. 2. The preponderance of the competent and credible evidence does not demonstrate that the Veteran's tinnitus had its onset during active service, manifested within one year of separation, or is otherwise etiologically related to service. 3. The preponderance of the competent and credible evidence does not demonstrate that the Veteran's currently diagnosed right foot degenerative arthritis had its onset during active duty service, manifested within one year of separation, or is otherwise etiologically related to service. CONCLUSIONS OF LAW 1. The criteria to establish entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2015). 2. The criteria to establish entitlement to service connection for tinnitus have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 3. The criteria to establish entitlement to service connection for a right knee disability have not been met. 38 U.S.C.A. § 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has thoroughly reviewed all the evidence in the claims file, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104 (West 2014); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). While the Board must review the entire record, it need not discuss each piece of evidence. Id. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. It should not be assumed that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board address its reasons for rejecting evidence favorable to the claimant. Id. The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). Equal weight is not accorded to each piece of evidence contained in the record, and every item of evidence does not have the same probative value. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Id. I. Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002); Dingess v. Nicholson, 19 Vet. App. 473 (2006). The Board finds that the notice requirements have been satisfied by letters in July 2007 and October 2007. The Board also concludes that the duty to assist has been satisfied as all pertinent service records, post-service treatment records, Social Security Administration records, and lay statements are in the claims file. In addition, the Veteran underwent VA examinations in October 2015. In a December 2015 statement, the Veteran contends that the October 2015 VA audiological examination was not adequate. When VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran, through his accredited representative, questions the qualifications of the October 2015 VA examiner alleging that the VA examiner's professional education was nearly a decade out of date; and that the examiner's characterization of the Veteran's post-service occupational noise exposure was incorrect. Generally, the Board is entitled to presume the competence of a VA examiner unless specific challenges to a VA examiner's competency are raised by the Veteran. See Rizzo v. Shinseki, 580 F.3d 1288 (Fed. Cir. 2009); see also Cox v. Nicholson, 20 Vet. App. 563, 569 (2007). In this case, the Veteran claims that the VA examiner failed to address 2006 research that found that "even with apparent recovery of normal hearing after acoustic trauma there can be widespread and ongoing damage to the cochlear hairs and their nerves becoming manifested over time." The Veteran did not raise any specific challenges to the October 2015 VA examiner's competency beyond her not addressing a specific 2006 study. The October 2015 VA examiner is a board certified audiologist. Accordingly, the Board must presume that the VA examiner has the requisite knowledge of current audiological research to provide an adequate etiological opinion. Indeed, as discussed below, the October 2015 VA examiner made specific references to medical research in her opinion. As such, the Board finds that the October 2015 VA examiner is competent to administer the examination and provide an opinion, and that the examination is adequate because it is predicated on a full understanding of the Veteran's medical history, takes into consideration the Veteran's lay statements, and provides a sufficient evidentiary basis for the claim to be adjudicated. To the extent it is alleged that the examiner's characterization of the Veteran's post-service occupational noise exposure is faulty, the Board will elaborate further in the decision on the merits below. VA has provided the Veteran with every opportunity to submit evidence and arguments in support of his claim. The Veteran has not identified any outstanding evidence that needs to be obtained. All relevant evidence necessary for an equitable disposition of the Veteran's appeal of this issue has been obtained and the case is ready for appellate review. Lastly, as directed, the RO properly attempted to obtain additional medical records and the Veteran underwent adequate VA examinations for his claimed disabilities. The Board is satisfied that there was substantial compliance with its May 2015 remand directives. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). II. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic diseases, such as arthritis and organic diseases of the nervous system, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Organic diseases of the nervous system include sensorineural hearing loss and tinnitus. See Fountain v. McDonald, 27 Vet. App. 258 (2015). Service connection for chronic diseases may also be established by chronicity and continuity of symptomatology. See 38 C.F.R. § 3.303(b). Continuity of symptomatology may establish service connection if a claimant can demonstrate (1) that a condition was "noted" during service; (2) there is post-service evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). With respect to hearing loss, impaired hearing will be considered to be a disability under the laws administered by VA when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz (Hz) is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Court of Appeals for Veterans Claims (Court) has held that the threshold for normal hearing is from 0 to 20 decibels, and that higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The auditory thresholds set forth in 38 C.F.R. § 3.385 establish when hearing loss is severe enough to be service connected. Hensley at 159. Pertinent law further provides that a Veteran who served in the Republic of Vietnam during the Vietnam era shall be presumed to have been exposed during such service to an herbicide agent. 38 U.S.C.A. § 1116 (West 2014); 38 C.F.R. § 3.307(a)(6)(iii) (2015). For purposes of application of this legal presumption, service in the Republic of Vietnam means actual service in-country in Vietnam from January 9, 1962 through May 7, 1975, and includes service in the waters offshore, or service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. §§ 3.307(a)(6)(iii), 3.313(a) (2015). In this case, the evidence does not show that the Veteran served in Vietnam, or that he has been diagnosed with a presumptive disease for exposure to herbicides. Therefore, the Veteran is not entitled to consideration of presumptive service connection on this basis. See DD Form 214. Notwithstanding the provisions relating to presumptive service connection, a Veteran may establish service connection for a disability with proof of actual direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran is competent to describe the nature and extent of his in-service noise exposure. See C.F.R. § 3.159(a)(2); Washington v. Nicholson, 19 Vet. App. 362, 368 (2005); Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Bilateral Hearing Loss and Tinnitus The Veteran contends that he developed bilateral hearing loss and tinnitus as a result of his exposure to loud noises during his active duty service. Specifically, the Veteran described a history of noise exposure that began during boot camp when he received artillery training without hearing protection. Then, he recalled hearing the firing of weapons while he was stationed in Cuba where he had ground defense training. The Veteran also said he was trained, as an armed forces police officer, to fire a .38 caliber gun, .45 automatic gun, and a 12-gauge shot gun. Upon completion of his training, the Veteran said he served aboard the U.S.S. Shenandoah as a storekeeper. While aboard the ship, the Veteran said he heard metal flying, machinery, welding, and propellers turning. He explained that initially, he worked as a mess cook and then worked in the supply department. As a storekeeper, the Veteran said his duties were to drive a five-ton truck to bring supplies from the supply depot to the base. Finally, the Veteran reported that while stationed on a base outside Memphis, Tennessee, he learned to shoot a shot gun and served as a guard at the gates. The Veteran did not recall having hearing loss during service. See July 2010 Board hearing transcript. Military service records document that the Veteran served in the U.S. Navy, that his military occupational specialty was as a Storekeeper, and that he served aboard the U.S.S. Shenandoah. See DD Form 214. Service treatment records (STRs) include normal whisper test results at 15/15 bilaterally upon enlistment into the U.S. Navy Reserves and separation from active duty. See May 1964 enlistment examination and July 1968 separation examination. Upon entering active service into the U.S. Navy, the Veteran underwent audiological testing, which showed normal hearing for VA purposes. See June 1964 enlistment examination. No other audiological testing was performed during the Veteran's active duty service. An April 1968 STR documents that the Veteran complained of a right ear ache and received treatment for a middle ear infection. He was prescribed medication and did not return for additional treatment. At his July 1968 separation examination, the Veteran had normal clinical evaluation results. After the Veteran's discharge, a September 2007 VA treatment record reflects his first documented post-service treatment for hearing loss. The Veteran denied a history of military noise exposure and reported a history of occupational noise exposure from machinery or equipment. Following an objective evaluation, the VA treating audiologist diagnosed the Veteran with right moderate hearing loss at 6000 to 8000 Hz, mild hearing loss at 250 Hz, and left mild to moderate high frequency sensorineural hearing loss at 3000 to 8000 Hz. The VA treating audiologist found that the Veteran's slight asymmetry noted during pure tone testing was consistent with the Veteran's history of noise exposure. A March 2012 VA treatment record reflects that the Veteran reported having decreased hearing. He also reported having tinnitus, which he had noticed over the past couple of months. In October 2015, the Veteran underwent a VA audiological examination. The VA examiner noted the Veteran's account of his history of in-service and post-service noise exposure. Upon objective evaluation, including pure tone threshold testing, the VA examiner diagnosed the Veteran with bilateral sensorineural hearing loss. Following a review of the Veteran's claims file, including his medical records, and consideration of his lay statements, the VA examiner opined that the Veteran's bilateral hearing loss was less likely as not caused by, or a result of, military noise exposure. The VA examiner found that the configuration of the Veteran's current hearing loss was inconsistent with exposure to high intensity noise and more consistent with genetic or other disease process. Referring to the Veteran's 18-month history of in-service noncombat noise exposure as minimal and his 20-year history of occupational noise exposure as far greater, the VA examiner concluded that the Veteran's current hearing loss had a far less than 50/50 probability relationship to his military service than his exposure to hazardous noise in his civilian life. Citing the Noise Manual and OSHA regulations, the VA examiner noted that the degree of any noise-induced hearing loss is highly correlated with the intensity of the noise and the length of exposure time. Based on the findings of a medical study, the VA examiner found that there was insufficient evidence to determine whether permanent noise-induced hearing loss could develop much later in one's lifetime, long after the cessation of that noise exposure. With regard to the Veteran's tinnitus, the October 2015 VA examiner noted that tinnitus might occur following a single exposure to high-intensity impulse noise, long-term exposure to repetitive impulses, long-term exposure to continuous noise, or exposure to a combination of impulses and continuous noise. Finding that the Veteran did not have an objectively verifiable noise injury, which would be determined by an audiogram, the association between the Veteran's claimed tinnitus and noise exposure could not be assumed to exist. The VA examiner also explained that in most cases, tinnitus was accompanied by measurable hearing loss. Therefore, the VA examiner opined that the Veteran's tinnitus was less likely as not caused by, or a result of, military noise exposure. In December 2015, the Veteran submitted evidence, in the form of job function and duties information for human resources clerks, to support his contention that he was not exposed to significant occupational noise following his military service. The Veteran asserts that he worked as a human resources clerk and that the only machines that he worked with were computers, fax machines, printers and copiers. As mentioned in the introduction section, this conflicts somewhat with history recorded in the October 2015 VA examination report. Based on a careful review of all of the evidence, the Board finds that the preponderance of the evidence weighs against finding in favor of the Veteran's claim for service connection for bilateral hearing loss. The evidence demonstrates that the Veteran has a current bilateral sensorineural hearing loss diagnosis. In addition, the Board finds that the Veteran was exposed to some level of noise during his active duty service. However, the question remains whether the Veteran was exposed to sufficient noise during his active service to result in acoustic trauma leading to his current development of bilateral sensorineural hearing loss. The Board finds that the October 2015 VA examiner's opinion is the most probative evidence as to the etiology of the Veteran's current bilateral hearing loss. In concluding that the Veteran's bilateral hearing loss was not the result of his military noise exposure, the VA examiner found it significant that the Veteran's current hearing loss was more consistent with genetic or other disease process than high intensity noise. Furthermore, the VA examiner found that the Veteran's exposure to noise during service was minimal and short in duration and that his occupational noise exposure was more long-standing. While the Veteran disputes the VA examiner's characterization of his post-service occupational noise exposure, he does not specifically deny that he did not work with machinery as a mechanic; in any case, the VA examiner noted on her examination report the Veteran's account of his history of post-service occupational noise exposure, which included work as a mechanic/bookkeeper without hearing protection. To the extent that there was a misunderstanding regarding the degree of occupational noise exposure that the Veteran sustained post-service, the Board still finds that the October 2015 did not solely rely on such history of noise exposure to form her opinion. Actually, the VA examiner found that the Veteran's current hearing loss was not even consistent with high intensity noise. Therefore, despite the Veteran's argument that the VA examiner gave improper weight to his history of occupational noise exposure, the Board finds that the October 2015 VA examiner's opinion provides a sufficient rationale as it was based on a thorough review of the evidence, including consideration of the Veteran's medical records, his account of in-service noise exposure, and reference to medical literature. Thus, the Board concludes that the Veteran is not entitled to service connection for bilateral hearing loss on a direct basis. In addition, the Board finds that the preponderance of the evidence weighs against finding in favor of the Veteran's claim for service connection for tinnitus. The Board finds that the October 2015 VA examiner's opinion is the most probative evidence as to the etiology of the Veteran's tinnitus. Based on the VA examiner's conclusion that the Veteran had not sustained an objectively verifiable noise injury during service, as shown by a lack of hearing loss, the VA examiner opined that the Veteran's tinnitus was not related to any military noise exposure. As the VA examiner provided a well-reasoned opinion based on a thorough review of the evidence, the Board concludes that the Veteran is not entitled to service connection for tinnitus on a direct basis. The Board acknowledges that the Veteran contends that his exposure to hazardous noise in service caused his bilateral hearing loss and tinnitus. Lay evidence may (italics added for emphasis) be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Board finds, however, that the Veteran's assertion as to the etiology of his bilateral hearing loss is too medically complex to be made on lay observation alone. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Therefore, the Veteran's assertion that his bilateral hearing loss and tinnitus are the result of his in-service noise exposure is not deemed competent. Furthermore, the Board finds that the Veteran's December 2015 statement referring to a 2006 study to suggest that he had latent hearing loss due to his in-service noise exposure is not persuasive. This study is not specific to the Veteran and the findings are not based on the Veteran's history and circumstances. Evidence that is speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993). As the study is general in nature and does not specifically relate to the facts and circumstances surrounding this particular case, the Board finds that it offers little probative value. The Board has also considered whether the Veteran is entitled to service connection on a presumptive basis under 38 C.F.R. § 3.307(a), for bilateral sensorineural hearing loss or tinnitus, as "organic diseases of the nervous system." Here, the Board finds that neither the Veteran's bilateral hearing loss nor his tinnitus manifested to a degree of 10 percent or more within one year from the separation. The record shows that the Veteran first complained of hearing loss in 2007, almost 40 years after separation. Notably, the Veteran has not asserted that he has had hearing loss since he left service. In addition, the record shows that the Veteran first noticed his tinnitus in 2012, almost 45 years after separation. The Board finds that overall, the evidence demonstrates that the Veteran's bilateral sensorineural hearing and tinnitus did not manifest until many years after his service; therefore, the Veteran is not entitled to presumptive service connection for either his bilateral hearing loss or tinnitus. In summary, the Board finds that the Veteran is not entitled to service connection on a direct or presumptive basis bilateral hearing loss or tinnitus. Consequently, the benefit-of-the-doubt rule does not apply, and service connection must be denied. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55. Right Foot Disability The Veteran testified at his July 2010 Board hearing that his current right foot problems are related to a right foot laceration he sustained during service while serving aboard a naval ship. In particular, the Veteran recounted that early in the morning, man overboard quarters was called, and while responding to the alert, he jump out of his rack and landed directly onto a S hook that was on the floor. The Veteran said the injury was on the ball of his right foot and was the size of about an eighth or quarter of an inch. The Veteran said that he was taken to sick bay, that he was bleeding all over the place, that they had to dig the skin back out of his foot, and that his foot was bandaged. He did not receive any stitches. He was put on light duty. At no other time during his active service did the Veteran report having injured his right foot. He also did not receive any more treatment for his right foot during service. Following his discharge, the Veteran testified that he had a slight right leg limp due to pain. He admitted that, at his separation examination, no limp was noted, but he said the physical only lasted five minutes. For 30 to 35 years after his discharge, the Veteran did not seek any treatment for his right foot. When he began receiving treatment at VA by podiatry, the Veteran reported that VA put cream on his feet to keep them from getting raw, cut his nails, and massaged his feet. He also testified that most of his foot problems are due to his non-service-connected diabetes. Alternatively, the Veteran argues that he sustained nerve damage when he injured his right foot during service which resulted in his current right foot problems. STRs reveal that the Veteran suffered a laceration to his right foot in January 1967. The wound was cleaned and dressed. A day later, it was still tender. Another dressing was applied, and hot soaks were recommended. Three days later, the skin was noted to be avulsed in a 1.5 x 2 centimeter area over the metatarsals. The wound was still tender, but was found not to be infected. Another dressing was applied, and the Veteran was placed on light duty. At his July 1968 separation examination, his lower extremities were given a normal clinical evaluation. No scar was noted with respect to his right foot. Numerous VA treatment records from December 2006 to July 2015 document the Veteran's regular treatment in the podiatry clinic for thick, elongated fungal or painful nails. These records note that he is diabetic. Diagnoses of onychomycosis and onychauxis were rendered. Except as noted below, he affirmatively denied all other foot problems. A September 2007 VA treatment record reflects that the Veteran's gait was abnormal and he used a cane for stability. A September 2009 VA treatment record notes that the Veteran walked with a limp and used a cane. VA treatment records in November 2009 and October 2010 report that the Veteran's foot sensory examination results revealed partially insensate feet bilaterally. A foot inspection found corns and callouses. See October 2010 VA treatment record. His foot pulses were normal. Subsequent VA treatment records document normal results upon foot sensory examination, foot inspection (except for onychomycosis), and foot pulses. See November 2011, October 2012, June 2013, April 2014, and June 2013 VA treatment records. March 2010 and August 2010 VA treatment records document the Veteran's complaints of right foot pain located in the bones between digits two and three. Following an objective evaluation, the VA treating physician diagnosed the Veteran with Morton's neuroma. No treatment was requested. A May 2011 x-ray revealed mild degenerative changes in the right foot. A November 2011 VA treatment record reflects that the Veteran reported an old right foot injury had occurred in 1968 when an anchor fell on his right foot causing a puncture. No current right foot complaints or diagnosis was recorded. A January 2012 VA treatment record notes that an examination revealed exaggerated bilateral foot pronation. A July 2012 VA treatment record documents that the Veteran's foot hit his cane, he lost his balance, and he fell. Sore toes were his only injury. He was told to keep his foot elevated, to apply ice three to four times a day, and to take over-the-counter pain medication if needed. In October 2015, the Veteran underwent a VA foot examination. The Veteran reported his in-service right foot injury and his history of medical care for his foot both in-service and post-service. Upon objective evaluation, including a review of right foot x-ray results, the VA examiner diagnosed the Veteran with a right foot skin avulsion laceration, which had healed without residuals, and right foot degenerative arthritis. Based on a review of the Veteran's claims file, including his medical records, and consideration of his lay statements, the VA examiner opined that the Veteran's current right foot disability was less likely as not incurred in or caused by his in-service right foot laceration. Referring to current medical literature, the VA examiner discussed the pathology of osteoarthritis and the contributory or predisposing factors for osteoarthritis, including obesity, increasing age, repetitive joint overuse, joint trauma, and joint instability. In concluding that the Veteran's current right foot arthritis was unrelated to service, the VA examiner relied on a lack of chronicity of right foot complaints in the Veteran's STRs, including no evidence of bone or muscle involvement for his skin avulsion laceration and a normal separation examination; a lack of treatment post-service for any chronic right foot condition or complaint until 2009 (when the Veteran sought treatment for a right foot injury after hitting a metal frame at home and x-rays showed no evidence of fracture); and the finding of mild degenerative arthritis in 2011, which the VA examiner found to be commonly seen in his age group (65 or older). Ultimately, the VA examiner, citing medical literature, found that there was no support for a causal relationship between a skin avulsion laceration without infection and without muscle or bone involvement which had occurred in 1967 and degenerative arthritis diagnosed 44 years later, in 2011. Based on a careful review of the evidence, the Board finds that the preponderance of the evidence weighs against finding in favor of the Veteran's claim for service connection for a right foot disability. As the evidence demonstrates that the Veteran has a current right foot disability and there was an in-service right foot injury, resulting in a skin avulsion laceration without residuals, the Board must now address whether the evidence shows that the Veteran's currently diagnosed right foot arthritis is etiologically related to this in-service injury. The Veteran stated that he developed a persistent slight right leg limp due to the pain following his right foot injury. Following his right foot injury in 1967, the Veteran also admitted that he never returned for further treatment during service for any foot problems and that his separation examination was negative for any foot problems or evidence of a limp. Notably, the Veteran reported that he did not seek any treatment for any foot-related problems for 30 to 35 years after his discharge. Of further significance, once the Veteran began to receive treatment for his right foot, more than 35 years after discharge, the overwhelming majority of his records show treatment for skin-related foot conditions, but no findings related to orthopedic foot conditions or complaints of right foot pain. Two isolated 2010 VA treatment records document a diagnosis for Morton's neuroma following a complaint of right foot pain; however, subsequent treatment records do not reflect any further treatment related to the diagnosis. While there were sporadic references to the Veteran using a cane for stability, having an abnormal gait, and objective findings of the Veteran walking with a limp, the VA treatment records, for a period of nine years, do not reflect any chronic right foot orthopedic condition. Lastly, the Veteran was not diagnosed with arthritis until 2011, more than 40 years after service. Accordingly, the preponderance of the evidence demonstrates that the Veteran's currently diagnosed right foot arthritis did not manifest within one year of separation; and the Veteran is not entitled to service connection for his right foot disability on a presumptive basis, or by way continuity of symptomatology. 38 C.F.R. § 3.303(b); see Walker, supra. With regard to direct service connection, the Board similarly finds that the October 2015 VA examiner's opinion is the most probative evidence as to the issue of etiology. The October 2015 VA examiner considered the Veteran's in-service account and STRs, post-service history and medical records, as well as current medical literature, when the VA examiner opined that the Veteran's current right foot disability was not etiologically related to his in-service right foot skin avulsion laceration. As the October 2015 VA examiner provided a complete rationale, the Board finds that the evidence demonstrates that the Veteran's current right foot disability is not etiologically related to his in-service right foot injury. The Board acknowledges that the Veteran has also asserted that he experienced nerve damage as a result of his in-service foot injury which caused his current right foot disability. Nevertheless, the Veteran has not provided any medical evidence of such nerve damage in his right foot either during service or since his separation. Indeed, within the Veteran's significant documented treatment for his feet, there were only two references to abnormal foot sensory examination results, without any indication that further testing was required or that any nerve-related problems were involved. Accordingly, the Board finds that further consideration of such a theory is not warranted as it is disputed by the evidence of record. Finally, the Veteran is competent to report his continuous symptoms of right foot pain and that he had a persistent right leg limp due to the pain. However, for similar reasons as described above, the Board finds that the Veteran's reported symptoms of right foot pain since separation from service is not credible, because it is contrary to, and significantly outweighed by, the significant medical and circumstantial evidence. In this regard, the Board highlights that the Veteran failed to consistently report symptoms of right foot pain during his regular podiatry clinic visits. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (the silence in a medical record can be weighed against lay testimony if the alleged injury, disease, or related symptoms would ordinarily have been recorded in the medical record being evaluated by the fact finder). In summary, to the extent the Veteran contends that his currently diagnosed right foot disability must be related to his 1967 right foot injury, such contention is outweighed by great weight of evidence of record, as described above. Thus, the Veteran is not entitled to service connection for a right foot disability on a direct or presumptive basis, therefore, the benefit-of-the doubt rule does not apply, and the service connection must be denied. See 38 U.S.C.A. § 5107(b); Gilbert, 1 Vet. App. at 55. ORDER Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for a right foot disability is denied. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs