Citation Nr: 1753056 Decision Date: 11/17/17 Archive Date: 11/22/17 DOCKET NO. 11-03 508 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for joint pain, to include as due to an undiagnosed illness or other qualifying chronic disability, pursuant to 38 C.F.R. § 3.317. 2. Entitlement to service connection for gastrointestinal symptoms and kidney problems to include as due to an undiagnosed illness or other qualifying chronic disability, pursuant to 38 C.F.R. § 3.317. 3. Entitlement to a rating in excess of 10 percent for service-connected tinea versicolor. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Parrish, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1988 to March 1992, which included service in the Southwest Asia Theater of operations during the Persian Gulf War. These matters come before the Board of Veterans' Appeals (Board) on appeal from April 1998 and July 2008 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In October 1998, the Veteran testified before a Hearing Officer at the RO. In August 2015, the Veteran testified at a Travel Board Hearing before a Veterans Law Judge (VLJ). A transcript of the hearing is of record. In September 2017, the Veteran was notified that the VLJ who conducted his hearing was no longer with the Board. The Veteran was provided the opportunity to appear for another Board hearing, but no response was received. Pursuant to the letter, when no response is received within 30 days of the letter, the Board will assume no hearing is requested and proceed with adjudication. In December 2015, the Board remanded these matters for further development. In a February 2017 decision and remand, the Board re-opened the Veteran's claim for entitlement to service connection for a multisymptom undiagnosed illness manifested by joint pain and remanded that issue, along with the other issues on the title page, for further development. FINDINGS OF FACTS 1. The Veteran's joint pain did not have its onset in service, arthritis did not manifest to a compensable degree within one year of separation from service, and is not otherwise related to service, to include as due to an undiagnosed illness or other qualifying chronic disability, pursuant to 38 C.F.R. § 3.317. 2. The Veteran's gastrointestinal and kidney disorders (diagnosed as diverticulosis, chronic constipation and chronic renal insufficiency) did not have onset in service, and are not otherwise related to service, to include as due to an undiagnosed illness or other qualifying chronic disability, pursuant to 38 C.F.R. § 3.317. 3. Throughout the appeal period, the Veteran's tinea versicolor, at worst, resulted in infections of the skin covering a total body area of 5 to 20 percent and less than 5 percent in an exposed area and did not require systemic or topical corticosteroid or other immunosuppressive drugs as treatment. CONCLUSIONS OF LAW 1. The criteria for establishing service-connection for joint pain, to include as due to an undiagnosed illness or other qualifying chronic disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.317 (2017). 2. The criteria for service connection for gastrointestinal symptoms and kidney problems, to include as due to an undiagnosed illness or other qualifying chronic disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1117, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.317 (2017). 3. The criteria for a rating in excess of 10 percent for tinea versicolor have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.118, Diagnostic Codes (DCs) 7813-7806 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 (2017). Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1131 (2012); 38 C.F.R. § 3.303 (2017). That determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d) (2017). Service connection may be presumed for certain chronic diseases, to include arthritis, which develop to a compensable degree within one year after discharge from service, even though there is no evidence of such disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. 3.307, 3.309(a) (2017). Where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has that chronic disability, service connection can be granted. That does not mean that any manifestations in service will permit service connection. To show 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 as distinguished from merely isolated findings or a diagnosis including the word chronic. When the disease entity is established, there is no requirement of evidentiary showing of continuity. 38 C.F.R. § 3.303(b) (2017). If there is no evidence of a chronic condition during service or an applicable presumptive period, then a showing of continuity of symptoms after service may serve as an alternative method of establishing service connection. 38 C.F.R. § 3.303(b) (2017). Continuity of symptoms may be established if a claimant can demonstrate (1) that a condition was noted during service; (2) evidence of post- service continuity of the same symptomatology and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. If service connection is established by continuity of symptomatology, there must be medical evidence that relates a current condition to that symptomatology. Continuity of symptoms applies only to those conditions explicitly recognized as chronic. 38 C.F.R. § 3.309(a) (2017); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Additionally, pursuant to 38 U.S.C.A. § 1117, a Persian Gulf Veteran with a qualifying chronic disability that manifests to a degree of 10 percent or more before December 31, 2021, may be entitled to compensation. See 38 U.S.C § 1117 (2012); 38 C.F.R. § 3.317(a)(1) (2017). There are three avenues for finding that a chronic disability may qualify for presumptive service connection pursuant to 38 U.S.C. § 1117. Qualifying chronic disabilities include those that result from (1) an undiagnosed illness, (2) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders, or (3) any diagnosed illness that the Secretary determines in regulations . . . warrants a presumption of service connection. 38 U.S.C § 1117(a)(2)(A), (B), (C); 38 C.F.R. § 3.317(a)(2)(i)(B). A medically unexplained chronic multi-symptom illness is "a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities." 38 C.F.R. § 3.317(a)(2)(ii). Disabilities that have existed for 6 months or more and disabilities that that exhibit intermittent episodes of improvement and worsening over a 6-month period will be considered chronic. 38 C.F.R. § 3.317(a)(4). A qualifying chronic disability shall be rated using the criteria from part 4 of the chapter for a disease or injury which the functions affected, anatomical localization, or symptomology are similar. 38 C.F.R. § 3.317(a)(4). Along with the three examples of a medically unexplained chronic multi-symptom illness provided by § 1117(a)(2)(B), the law provides a list of signs or symptoms that may be a manifestation of a medically unexplained chronic multi-symptom illness that includes: skin symptoms, headaches, muscle pain, joint pain, neurologic symptoms, neuropsychological symptoms, respiratory symptoms, sleep disturbances, gastrointestinal symptoms, cardiovascular symptoms, abnormal weight loss, and menstrual disorders. See 38 U.S.C. § 1117(g); 38 C.F.R. § 3.317(b). Initially, the Board notes it has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to each claim. Factual Background The Veteran's service treatment records (STRs) are void of complaints of or treatment for joint, gastrointestinal, or kidney issues or complaints. His April 1988 enlistment examination had no findings regarding his joints, gastrointestinal, or renal system. Similarly, the Veteran's January 1992 separation examination did not have any findings regarding either his joints, gastrointestinal, or renal system. A June 1996 VAMC record indicated the Veteran had pain in his right groin for a long period after being hurt on the job. He described his pain as a "pulling" sensation down to his medial thigh. X-rays of his hips and pelvis were noted to be normal. A CT scan of his abdomen was normal. At a November 1997 VA bone examination the Veteran reported no injury, episodes of osteomyelitis, or surgery. He denied symptoms of pain, weakness, stiffness, swelling, heat, redness, drainage, instability or giving way, "locking", or abnormal motion. He denied flare-ups. He did not report use of assistive devices. No constitutional symptoms of bone disease were present. There was no malunion, nonunion, loose motion, or false joint. No ankylosis was present. There was no abnormality of the bones noted. X-rays of the Veteran's knees indicated that there was upper polar patellar spurring bilaterally and no evidence of acute fracture or dislocation. X-rays of his right and left shoulders found no evidence of acute fracture or dislocation. In February 1998, a VAMC general note indicated the Veteran had been experiencing pain in his left knee for a long time. An April 1998 VAMC X-ray of the Veteran's knees indicated he had degenerative spurs. A July 1998 VAMC medical record indicated the Veteran complained of left knee pain, which he had been experiencing for the past several months. He reported having twisted his knee one month prior. He also reported increased discomfort in his knees and left shoulder. X-rays of the Veteran's feet demonstrated no recent fracture or dislocation. Minimal posterior plantar calcaneal spurs were noted. An August 1998 VAMC podiatry note reported the Veteran had X-rays of his feet which showed plantar and post calcaneal spurs bilaterally. An August 1998 VAMC left shoulder X-ray showed no demonstrable recent fracture, dislocation, or other gross osseous pathology. In October 1998, the Veteran testified at a hearing before a hearing officer that he had joint pain which felt like his bones were rubbing against each other. He stated that everything was just real loose and his knees were getting to the point to where he was wearing braces. He stated that the X-rays showed that everything was fine, but that everything was also moving. He stated it was all his joints, but that his knees were the worst. He reported being on pain killers and anti-inflammatories. He did not have a diagnosis because the doctors could not find anything wrong with him other than complaints of continual pain and discomfort. He stated that he noticed the symptoms when he first got out of service and also stated that he did not receive treatment for joint problems in-service. He took medication two to three times a day as needed for pain. A October 1998 VAMC nursing telephone note indicated the Veteran called in for an appointment due to kidney pain. The Veteran was seen for abdominal pain on and off for the prior 4 days. He described the pain as located on both lateral aspect of his abdomen. He denied fever, no nausea, vomiting, or diarrhea, but he stated that he was more or less constipated. His abdominal examination revealed mild tenderness of both lateral aspect of abdominal wall muscles, but no other tenderness or rigidity. The abdomen was soft and benign and had normal bowel sounds. The gastrointestinal findings were within normal limits. In November 1998, an acquaintance of the Veteran's submitted a lay statement indicating that the Veteran had been suffering from joint pain which impacted his ability to be active. The statement also indicated that the Veteran had once been very active but no longer wanted to do anything because he was always hurting. In March 2007, a VAMC urology consult note indicated the Veteran presented with right lower quadrant pain which extended to the right testes and first begin in 1996. Upon examination, the Veteran's abdomen was not tender and had no discernable masses. There was no demonstrable inguinal hernia. A July 2007 VAMC abdominal echogram indicated the Veteran's liver appeared normal. The right kidney was normal. The impression was no evidence of a lower right quadrant mass and a contracted but probably normal gallbladder. In September 2007, a right upper quadrant sonogram at a VAMC indicated the Veteran's gallbladder, liver, right kidney, and abdominal aorta were unremarkable in appearance. The impression was a normal right upper abdominal quadrant; the pancreas was not delineated. A September 2007 VAMC practitioner note indicated the Veteran had a history of right lower quadrant pain which had been present for 10 years prior. The Veteran described it as a pulling sensation which was unaffected by urinating, eating, movement. Flexing forward may "ease it off." In January 2008, a VAMC gastroenterology consult note indicated the Veteran had pain radiating from the right lower quadrant to the right testicle since 1996. Onset of pain began with lifting a heavy bucket when he felt a small "pop" and then the pain began. The pain was exacerbated with lifting, erections. The pain was improved with bending, lifting knees, and curling into the fetal position. The Veteran denied rectal bleeding, hematochezia, melena, and hemorrhoids. An abdominal CT and double contrast barium enema was normal save for a possible ceceal mass, which was thought to be stool. The impression was that the pain had an unlikely gastrointestinal source. In July 2010, a VAMC CT of the abdomen indicated that the Veteran's pancreas, spleen, bladder, kidneys, and the adrenals appeared unremarkable. No abdominal or pelvic lymphadenopathy was seen. The prostate was not enlarged. Diverticulosis of sigmoid colon was seen. In August 2010, a VAMC urology note indicated the Veteran had a long history of right lower quadrant pain. A recent CT scan was noted to show a filling defect in the colon. In January 2014, a VAMC X-ray report indicated the Veteran's left should had no evidence of a fracture, dislocation, or bony lesion. His visualized joints were well maintained and there were no significant degenerative changes noted. An X-ray of the Veteran's right ankle showed normal bony alignment without fracture, dislocation or soft tissue swelling. In April 2014, a VAMC chiropractic consult note indicated the Veteran had complaints of bilateral shoulder pain, wrist pain, pain in the left knee and right ankle. In June 2014, a VAMC podiatry consult note indicated the Veteran complained of arch and ankle pain along both feet. The Veteran denied any recent trauma. He was diagnosed with planter facitits, bilaterally. In February 2015, a VAMC X-ray of the Veteran's hips indicated he had moderate bilateral degenerative changes with changes of I lateral femoral acetabular impingement. The assessment was that the Veteran had bilateral hip osteoarthritis with femoral-acetabular impingement syndrome. His arthritis was determined to be very advanced for someone his age. A February 2015 VAMC orthopedic surgery consult note reported the Veteran had an examination in February 2015 wherein he was found to have moderate degenerative changes in his hips, as well as femoral-acetabular impingement syndrome, which was not found to be significantly different from a prior October 2008 study. An April 2015 VAMC primary care note reported the Veteran had presented with left greater than right hip pain. He was recommended for hip steroid injections. In June 2015, a VAMC procedure note indicated the Veteran had hip pain and possible arthritis, but no diagnostic confirmation. He received a steroid injection in his left hip. In his August 2015 hearing testimony the Veteran stated that after returning from his time in Southwest Asia Theater of operation his joints started hurting and that he began getting steroid shots in his hips and in his shoulders. He also reported stomach pain since his return from deployment. He had never received a diagnosis for the causation of either his joint pain or his gastrointestinal issues. In January 2016, the Veteran reported to a VAMC emergency department with left shoulder pain that started a few days prior after pushing something. He denied previous shoulder injury. An X-ray showed no significant bony abnormality. In February 2016, a VAMC nursing telephone note reported the Veteran had complaints of left shoulder pain after he "pushed something" and felt pain. He then attributed his shoulder pain to a fall. In May 2016, a VAMC nursing note reported the Veteran had left shoulder pain after a fall while wrestling. In a June 2016 VA Gulf War General Medical Examination, the Veteran was not found to have any diagnosed illnesses for which no etiology was established, or additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness." The examiner stated that there was no objective evidence on history or physical exam of chronic fatigue syndrome, fibromyalgia, or irritable bowel syndrome as the established diagnostic criteria for those conditions were not met. The examiner did not find any conditions presumptive of Gulf War Environmental Hazards. The Veteran was determined to have chronic renal insufficiency, which the examiner stated was less likely caused by, or a result of, or aggravated beyond natural progression by, his active duty or a specific exposure event experienced by the Veteran during service in Southwest Asia as the medical literature did not support a cause and effect relationship between environmental exposure in Southwest Asia and the subsequent development of chronic renal insufficiency, years following the cessation of the exposure. The examiner also stated that there was no current objective evidence that the Veteran's claimed conditions were caused or permanently aggravated by his environmental exposures during deployment in Southwest Asia. In a concurrent June 2016 VA examination regarding his gastrointestinal complaints, the Veteran reported that he had pain in his abdomen for a long time. He reported pain in the right side of his abdomen going down into his testicle. He reported his pain was worse if he was doing something strenuous. He denied diarrhea and stated that his pain was not relieved by having a bowel movement. He was diagnosed with chronic constipation and diverticulosis. He was found to have abdominal distension and vomiting. He did not have episodes of bowel disturbance with abdominal distress, weight loss attributable to an intestinal condition, or malnutrition. Upon examination, his abdomen was essentially unremarkable - soft, with no organomegaly. There was tenderness with no rebound right lower quadrant, no hernia appreciated. The examiner noted a subcutaneous mass - lipoma or cyst. The examiner stated that the Veteran's chronic constipation and diverticulosis were not due to service, to include service in southwest Asia, as the Veteran's STRs and available medical record within two years of active duty were silent for chronic constipation and diverticulosis. Furthermore, the examiner found that medical literature did not support a cause and effect relationship between environmental exposures in Southwest Asia and the subsequent development of chronic constipation and diverticulosis years following the cessation of the exposure. The examiner stated that there was no current objective evidence that the Veteran's conditions were caused or permanently aggravated by his environmental exposures during deployment in Southwest Asia and noted that chronic constipation and diverticulosis were not Gulf war presumptive conditions. An August 2016 VAMC MRI of the left shoulder found a full-thickness tear of the mid and anterior fibers of the supraspinatus with retraction to beneath the acromion and a small instrasubstance tear of the infraspinatus. In September 2016, a VA orthopedic consult note reported the Veteran had left shoulder pain since 1995. He reported an injury 2-3 months prior when he was wrestling. In a March 2017 VA Gulf War General Medical Examination, the Veteran was not found to have any diagnosed illnesses for which no etiology was established or additional signs and/or symptoms that may represent an "undiagnosed illness" or "diagnosed medically unexplained chronic multisymptom illness." The Veteran was found to have residuals of a left shoulder rotator cuff repair with degenerative joint disease, osteoarthritis of the bilateral hips, calcaneal spurs, and bilateral patellar spurring. The examiner stated that upon review of the record and examination of the Veteran, there were no undiagnosed or diagnosable but medically unexplained/partially explained chronic multisymptom illnesses of unknown etiology attributable to environmental exposures during deployment in Southwest Asia. The examiner noted that there was objective evidence of the above diagnosed conditions and that none of the disorders were found to be Gulf War presumptive conditions. Furthermore, the examiner also found it less likely as not that the Veteran's diagnosed joint disorders were caused by, or a result of, or aggravated beyond natural progression by, his active duty service or a specific exposure event experienced by the Veteran during service in Southwest Asia. The examiner found that the joint disorders did not present during active duty or within close proximity of separation from service. Furthermore, there was no evidence to support that the joint disorders were due to exposure during deployment in southwest Asia as the medical literature did not support a cause and effect relationship between environmental exposures in Southwest Asia and the subsequent development of the joint disorders, years following the cessation of the exposure. A concurrent March 2017 VA fibromyalgia examination determined the Veteran neither currently had nor had ever been diagnosed with fibromyalgia. Upon examination, the Veteran did not have any findings, signs or symptoms attributable to fibromyalgia. A March 2017 addendum VA opinion to the June 2016 VA examination of the Veteran's gastrointestinal system again determined that the Veteran did not have an undiagnosed illness or chronic disability. The examiner stated that the Veteran's gastrointestinal conditions were determined to be chronic constipation, diverticulosis, and chronic renal insufficiency, which did not constitute undiagnosed illnesses or chronic disabilities caused by medically unexplained illnesses. The examiner went on to state that the listed conditions were not undiagnosed - chronic constipation, diverticulosis, and chronic renal insufficiency were specific diagnoses and were not medically unexplained. Specifically, the examiner stated that chronic constipation had a varied etiology, but could be identified and it was not unexplained, as dietary factors were commonly involved, as were opioid medications. Similarly, environmental and lifestyle factors - diet, lack of exercise, obesity, smoking - were important risk factors for diverticular disease. Finally, chronic renal insufficiency was noted to be a laboratory evaluation with BUN and creatinine, as well as analysis of the urine. Similar to constipation, the causes of renal insufficiency were many and varied but it was possible to determine the cause with proper testing. In the Veterans case, the examiner noted that creatinine elevation was attributed to medication use for non-service connected conditions. Ultimately, the examiner found that the Veteran's gastrointestinal symptoms and kidney problems did not constitute a functional diagnosable disability or disabilities and were not attributable to service. Joint Disorder In light of the above, the Board finds that service connection for a joint disorder, to include as due to an undiagnosed illness or other qualifying chronic disability, pursuant to 38 C.F.R. § 3.317, is not warranted. Direct service connection necessitates a finding that the Veteran's joint disorders are related to an injury or disease incurred in service. The evidence of record does not support such a finding. The Veteran's STRs are void of treatment for or complaint of symptoms associated with his joints. Specifically, the January 1992 separation examination did not find any abnormalities or complaints regarding his joints. The Veteran has also testified that his joint pain did not begin in service. The first medical evidence of record of joint pain was the November 1997 VA bone examination, which determined that he had bilateral patella spurring. His complaints of left shoulder pain were first documented in July 1998 and he was not diagnosed with a left shoulder rotator tear and arthritis until 2016, after reporting a fall injury. The Veteran's ankle pain was documented in July 1998 and diagnosed as plantar calcaneal spurs at that time. His hip disorder was first documented by X-ray in February 2015, when he was diagnosed with acetabular impingement and osteoarthritis. Thus, the documented evidence of the Veteran's joint disorders all occurred over at least four years after his separation from service. The passage of many years between discharge from active service and the documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F. 3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Additionally, there is no evidence of record which established that the Veteran was diagnosed with arthritis or any of his joint disorders within one year of his active service. The medical evidence of record also does not indicate that the Veteran was treating for any of his joint disabilities from the time of his active service to the date of his diagnosis of each of these disabilities. Thus, there is no evidence of record which establishes that the Veteran had continuity of symptoms for any of his diagnosed joint disorders since the end of his active service. Furthermore, the 2017 VA examiner did not relate the Veteran's diagnosed joint disorders to his time in service, including opining that the Veteran's joint disorders had not been aggravated beyond their normal progression by his service. The examiner stated that the Veteran's diagnosed joint disorders were less likely than not related to an injury or disease incurred in active service, due to the length of time between service and diagnosis. Presumptive service-connection via 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317 is also not established in regards to the Veteran's diagnosed joint disorders. Though the Veteran did have active duty service in the Southwest Asia Theater of operations during the Persian Gulf War, none of his diagnosed joint disorders - patella spurring, left shoulder arthritis, bilateral plantar calcaneal spurs, acetablular impingement syndrome and osteoarthritis of the hips - are included on the list conditions afforded presumptive service connection. Furthermore, as the VA examiners explained, the Veteran's disorders are all known clinical conditions and are neither undiagnosed illnesses nor manifestations of medically unexplained chronic multisymptom illnesses. 38 C.F.R. § 3.317(a)(1)(i)-(ii). Additionally, the examiners did not find evidence that the Veteran's diagnosed disorders were aggravated beyond their normal progression by the Veteran's service, including his service in Southwest Asia. Accordingly, the Board finds that service connection for the Veteran's diagnosed joint disorders cannot be granted under the presumptive provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317. The Board finds the 2016 and 2017 VA examiners' medical opinions are highly probative to the issue of whether the Veteran's joint disorders were related to service, including his Southwest Asia service. The examiners possess the necessary education, training, and expertise to provide the requested opinions. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The opinions were based on a review of the claims file and examination of the Veteran. The examiners' review of the Veteran's claims file consisted of his service treatment records and post-service medical evidence, and his contentions, upon which the examiners relied upon in giving their opinions and it is clear that the examiners took into consideration all relevant factors in giving their opinions. Significantly, the Veteran has not presented or identified any contrary medical opinion that supports the claims for service connection for any of his joint disorders. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991). The Board finds that the only medical opinion evidence of record shows that the Veteran's joint disorders are not related to service, to include his service in the Southwest Asia Theater of operations. The Board has also considered the lay statements of evidence, including the Veteran's statements regarding his joint disorders and his service in the Southwest Asia Theater of operations and his hearing testimony. However, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428 (2011), as to the specific issues being decided herein, an opinion as to the etiology of the Veteran's joint disorders, and whether they are etiologically related to the Veteran's active service, including his service in Southwest Asia, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Nothing in the record demonstrates that the Veteran, or any person submitting a lay statement, received any special training or acquired any medical expertise in the evaluation of such disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. In sum, the claims file does not contain competent and credible evidence that the Veteran's joint disorders are related to service, including his service in Southwest Asia. Accordingly, as the preponderance of the evidence is against the claim for service connection, the benefit-of-the-doubt rule is not for application, and the claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Gastrointestinal and Kidney Disorder The Board also finds that Veteran's gastrointestinal and kidney disorders do not warrant service connection, on either a direct or presumptive basis. The Veteran's STRs are void of treatment for or complaint of symptoms associated with either his gastrointestinal system or his kidneys. Specifically, the January 1992 separation examination did not find any abnormalities or complaints regarding his gastrointestinal system or kidneys. The Veteran has also testified that his gastrointestinal system or kidney pain did not begin in service, stating that his symptoms began after his return from deployment. The first notation of any type of abdominal pain was his June 1996 complaint of groin pain which he associated with a work injury. Furthermore, this complaint was four years after the Veteran separated from service. In a January 2008 VAMC consult note, the Veteran again related his abdominal complaints to a work injury. The Veteran's gastrointestinal and kidney disorders were diagnosed at the earliest in 2010, when he was found to have diverticulosis of the colon. Thus, the documented evidence of the Veteran's gastrointestinal and kidney disorders all occurred over at least four years after his separation from service and were related by the Veteran on two separate occasions to a work injury. As previously stated, the passage of many years between discharge from active service and the documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Furthermore, the 2015 examiner stated that the Veteran's diagnosed gastrointestinal and kidney disorders were less likely than not related to an injury or disease incurred in active service, due to the length of time between service and diagnosis. Presumptive service-connection is also not established in regards to the Veteran's gastrointestinal or kidney disorders. Though the Veteran did have active duty service in the Southwest Asia Theater of operations during the Persian Gulf War, the specific gastrointestinal and kidney disorders from which the Veteran suffers are not disabilities afforded such presumptive service-connection. As the VA examiners explained, diverticulosis, chronic constipation, and chronic renal insufficiency are known clinical disorders and not undiagnosed illnesses or manifestations of a medically unexplained chronic multisymptom illness. These disorders are also not included on the list of presumptive diseases. 38 C.F.R. § 3.317 (a)(1)(i)-(ii). Furthermore, both of the VA examiners found that the Veteran's gastrointestinal and kidney disorders were less likely than not due to the Veteran's Southwest Asia service as there was no support for a cause and effect relationship between these disorders and environmental exposures in Southwest Asia. Additionally, the examiners did not find evidence that the Veteran's diagnosed disorders were aggravated beyond their normal progression by the Veteran's service, including his service in Southwest Asia. Accordingly, the Board finds that service connection for gastrointestinal or kidney disorders cannot be granted under the presumptive provisions of 38 U.S.C.A. § 1117 and 38 C.F.R. § 3.317. The Board finds the medical records in the Veteran's claims file highly probative to the issue of whether the Veteran's gastrointestinal or kidney disorders (diagnosed as diverticulosis, chronic constipation and chronic renal insufficiency) are related to service, including Southwest Asia service. The 2016 and 2017 VA examiners' medical opinions are highly probative to the issue of whether the Veteran's disorders were related to service, including his Southwest Asia service. The examiners possess the necessary education, training, and expertise to provide the requested opinions. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The opinions were based on a review of the claims file and examination of the Veteran. The examiners' review of the Veteran's claims file consisted of his service treatment records and post-service medical evidence, and his contentions, upon which the examiners relied upon in giving their opinions and it is clear that the examiners took into consideration all relevant factors in giving their opinions. Again, there is no contrary medical opinion that supports the claims for service connection for his gastrointestinal or kidney disorders. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin, 1 Vet. App. 171; Willis, 1 Vet. App. 66. The Board finds that the only medical opinion evidence of record shows that the Veteran's gastrointestinal and kidney disorders are not related to service, to include his service in the Southwest Asia Theater of operations. The Board has also again considered the lay statements of evidence, including the Veteran's statements regarding his gastrointestinal and kidney disorders and his service in the Southwest Asia Theater of operations and his hearing testimony. Although the Veteran is competent to describe observable symptoms of his gastrointestinal and kidney disorders, he is not competent to opine as to the etiology of such disorders, as he has not been shown to possess the requisite training or credentials needed to render a competent opinion as to medical diagnosis or causation. Jandreau, 492 F.3d 1372; Barr v. Nicholson, 21 Vet. App. 303 (2007). As such, his lay opinion that his back disability was aggravated by active service does not constitute competent medical evidence and lacks probative value. In sum, the claims file does not contain competent and credible evidence that the Veteran's gastrointestinal or kidney disorders (diagnosed as diverticulosis, chronic constipation and chronic renal insufficiency) are related to service, including his service in Southwest Asia. Accordingly, as the preponderance of the evidence is against the claim for service connection, the benefit-of-the-doubt rule is not for application, and the claims must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. Part 4 (2017). When a question arises as to which of two ratings applies under a particular Diagnostic Code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating applies. 38 C.F.R. § 4.7 (2017). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran. 38 C.F.R. § 4.3 (2017). The Board notes that where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Veteran's tinea versicolor is currently assigned a 10 percent evaluation, as of the July 7, 1997, grant of service connection, pursuant to DCs 7813-7806. See 38 C.F.R. § 4.118. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after a hyphen. Regulations provide that when a disability not specifically provided for in the rating schedule is encountered, it will be rated under a closely related disease or injury in which not only the functions affected, but the anatomical localization and symptomatology are closely analogous. 38 C.F.R. § 4.20. DC 7813 provides ratings for dermatophytosis (or ringworm) in various locations on the body, including the body (tinea corporis), the head (tinea capitis), the feet (tinea pedis), the beard (tinea barbae), the nails (tinea unguium), and the inguinal area, also known as jock itch (tinea cruris). DC 7813 specifically provides that dermatophysosis is to be rated as disfigurement of the head, face, or neck (DC 7800), scars (DC 7801, 7802, 7803, 7804, or 7805), or dermatitis (DC 7806), depending upon the predominant disability. 38 C.F.R. § 4.118. Under DC 7806, a noncompensable rating is warranted when less than 5 percent of the entire body or less than 5 percent of exposed area is affected, and no more than topical therapy is required during the past 12-month period. A 10 percent rating requires that at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas be affected, or intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of less than 6 weeks during the past 12-month period. A 30 percent rating requires that 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas be affected, or systemic therapy such as corticosteroids or other immunosuppressive drugs for a total duration of 6 weeks or more, but not constantly, during the past 12-month period. A 60 percent rating requires more than 40 percent of the entire body, or more than 40 percent of exposed areas be affected, or constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs during the past 12-month period. 38 C.F.R. § 4.118, DC 7806 (2017). The provisions of DC 7806 also provides for a rating of disfigurement of the head, face, or neck (DC 7800) or scars (DCs 7801, 7802, 7803, 7804, or 7805), depending upon the predominant disability. An April 2009 VAMC dermatology note indicated the Veteran had chronic tinea versicolor which spread to his face and arms. The Veteran reported he was unable to adequately reach his back with Nizoral shampoo and Clotrimazole and gets extensive versicolor, which was pruritic. In June 2008, a VAMC dermatology consult note indicated the Veteran had a history of tinea versicolor which had been prescribed various topical medications without resolution. Upon examination, there was no active rash noted on the Veteran's face. His back and chest presented with class tinea versicolor. He was prescribed shampoo and topical cream. In June 2009, a VA examination of the Veteran's skin indicated he had tinea versicolor, which flared during the summer time. He stated he used Clotrimazole cream and Ketoconazole shampoo. He used the Clotrimazole daily. He used the Ketoconazole shampoo once weekly. The examiner stated that neither Clortrimazole nor Ketoconazole was a corticosteroid or an immunosuppressive. There were no side effects of the treatment noted. Less than 5 percent of the exposed area was affected. The total body area affected was greater than 5 percent and less than 20 percent. Upon examination his skin was found to have numerous, well-marginated, finely scaly, hyperpigmented, oval-to round macules of different sizes scattered over the posterior trunk and upper arms. Only few lesions were present on the neck. A September 2009 VAMC dermatology note indicated the Veteran had versicolor, which had improved. It was noted that it was cosmetically disturbing to the Veteran. An August 2013 private medical record found the Veteran to have pink and tan lightly scaly patches of the trunk, neck, and arm. He was started on prescription medication. A November 2013 VAMC emergency department note reported the Veteran to have no visible rash/lesion around his eyes, but to have flaky skin to his upper lids near his eyebrows, bilaterally. He had no visible rash/lesion around his mouth. He was prescribed prescription medication and cream. In January 2014, a VAMC primary care note indicated the Veteran had a dry, cracky, darker lip and skin around it, which started 2-3 months prior. He related that he had tried a local steroid, but that it did not help. He was diagnosed with periorbital eczema and dermatitis. He was advised to try a systemic steroid. In his August 2015 hearing testimony the Veteran stated that he was having breakouts on his scalp, neck, back, chest and arms. He stated that when he got hot and sweaty he would get pustules on his neck and back and that it burned. He reported that the condition was triggered by heat and that it affected his life by restricting activities that would result in him being overheated. He testified that the outbreaks lasted more than six weeks. In a February 2016 VA examination of the Veteran's skin, he was diagnosed with tinea versicolor. He reported that the condition went away and comes back. He reported blisters and pus. He stated that there were spots on his back which get swollen, like a bunch of open sores. The condition flared-up when he got hot or wherever it was warm on his body. He reported the lesions occurred on his scalp, face, lips, down his arms and under his arms. The examiner stated that the Veteran's report of pus bumps and spots that get swollen was not a description of his service-connected tinea versicolor as tinea versicolor does not result in raised lesions or bumps. The examiner also stated that the Veteran's tinea versicolor was not present on his scalp, face, beard, groin area, or underarms. The examiner found that the Veteran's described skin condition was mostly due to non-service-connected related etiologies. Upon examination, the Veteran was not found to have tinea versicolor on his head, face, or neck. He treated with anti-fungal creams/lotions for 6 weeks or more within the past 12 months, but not constant. He did not have debilitating episodes or non-debilitating episodes within the 12 months prior. Less than 5 percent of his total body was found to be affected, and 0 percent of his exposed body area was affected. No extensive lesions or marked disfigurement was found and no systemic therapy such as corticosteroids or other immunosuppressive drugs were requested during the past 12 months. The examiner also stated that tinea versicolor was not treated with any type of immunosuppressive therapy. In a March 2017 VA addendum opinion, a VA examiner stated that Clotrimazole was a synthetic antifungal agent and not a corticosteroid (neither topical nor systemic) and was not in any way similar to a corticosteroid. Further, the examiner stated that Clotrimazole was not an immunosuppressive medication and was not in any way similar to immunosuppressive medication. Consistent with a 10 percent rating under DC 7806, the weight of the evidence shows that the Veteran's tinea versicolor has affected more than 5 percent but less than 20 percent of the exposed areas and less than 5 percent of the total body. The 2009 VA examiner indicated that the Veteran's tinea versicolor involved more than 5 percent and less than 20 percent of the exposed areas and less than 5 percent of his total body. The Board notes that the February 2016 examiner observed some improvement, indicating that the Veteran's tinea versicolor involved less than 5 percent of the total body area and no exposed area. Throughout the appeal period, the medical evidence of record reflects periodic use of topical cream and a shampoo for treatment of the Veteran's tinea versicolor. As a result, the Board finds that the evidence is consistent with a 10 percent rating for the entire period on appeal for his service-connected tinea versicolor. At no point during the appeal period does the evidence of record demonstrate that a rating in excess of 10 percent for tinea versicolor is warranted. The competent evidence of record does not show that the Veteran's tinea versicolor is characterized by 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. See 38 C.F.R. 4.118, DC 7806 (2017). Though a 2014 VAMC record indicated the Veteran was advised to try a systemic steroid, there is no indication the Veteran was actually prescribed such a steroid, that he did use a systemic steroid, or that such a steroid was prescribed for the treatment Veteran's tinea versicolor. Thus, the evidence of record does not establish that the Veteran had use of a systemic steroid for the treatment of his service-connected tinea versicolor. Furthermore, both the 2009 and 2016 VA examiners stated that the Veteran was not using systemic therapy, corticosteroids, or immunosuppressive drugs to treat his tinea versicolor. The 2017 VA addendum further clarified that Clotrimazole, the topical therapy prescribed to the Veteran, was a synthetic antifungal agent and not a corticosteroid (neither topical nor systemic) or an immunosuppressive medication and was not in any way similar to a corticosteroid or an immunosuppressive medication. Thus, the Board finds that the Veteran received only topical therapy throughout the appeal period, to include prescriptions for Clotrimazole and a shampoo, that are used externally and not intrinsic to the body. The Board has also considered whether the Veteran's tinea versicolor warrants an evaluation pursuant to any other applicable DCs. However, nothing in the evidence of record suggests that the Veteran's tinea versicolor has caused scarring or disfigurement. Thus, a rating pursuant to DCs 7800-7805 is not warranted. The Board finds the June 2009 and February 2016 VA examiners' medical opinions highly probative to the issue of the severity of the Veteran's tinea versicolor. Specifically, the examiners interviewed the Veteran and conducted a physical examination. Moreover, the examiners had the requisite medical expertise and had sufficient facts and data on which to base their conclusions. As such, the Board accords the VA examination opinions great probative weight. The Board has also considered the statements submitted by the Veteran in support of the claim, including his hearing testimony. The Board finds that the Veteran is a lay person and is competent to report observable symptoms he experiences through his senses such as the presence of his tinea versicolor and its symptoms. Layno v. Brown, 6 Vet. App. 465 (1994). However, he has not been shown to be competent to identify a specific level of disability according to the appropriate diagnostic codes. Competent evidence concerning the nature and extent of the Veteran's tinea versicolor has been provided by the medical personnel who have examined him during the current appeal and who have made pertinent clinical findings in conjunction with the examination. The medical findings, as provided in the examination reports, directly address the criteria under which his disability is rated. The Board finds that evidence is the most persuasive and outweighs the Veteran's statements in support of his claim. Accordingly, the Board finds that the claim for a rating in excess of 10 percent for service-connected tinea versicolor must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the doubt doctrine; however, as the preponderance of the evidence is against assignment of a higher rating, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. §§ 3.102, 4.3 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for joint pain, to include as due to an undiagnosed illness or other qualifying chronic disability, pursuant to 38 C.F.R. § 3.317, is denied. Entitlement to service connection for gastrointestinal symptoms and kidney problems, to include as due to an undiagnosed illness or other qualifying chronic disability, pursuant to 38 C.F.R. § 3.317, is denied. Entitlement to a rating in excess of 10 percent for tinea versicolor is denied. ____________________________________________ Lesley A. Rein Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs