Citation Nr: 1754501 Decision Date: 11/29/17 Archive Date: 12/07/17 DOCKET NO. 13-15 353 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to service connection for a left ankle disability. 2. Entitlement to service connection for a back disability, to include as secondary to a left ankle disability. 3. Entitlement to service connection for a right foot disability, to include as secondary to service connected disabilities. 4. Entitlement to service connection for bilateral hearing loss. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD B. Bodi, Associate Counsel INTRODUCTION The Veteran served on active duty for training from January 1984 to June 1984 and on active duty from December 1989 to February 1992 and from March 2003 to February 2004. This matter is before the Board of Veterans Appeals (Board) on appeal from a February 2007 and November 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Houston, Texas. The Veteran and his spouse testified before the undersigned Veterans Law Judge (VLJ) at a June 2017 video conference hearing at the VA RO in Houston, Texas. A copy of the hearing transcript has been associated with the claims file. FINDINGS OF FACT 1. Chronic left ankle pain is attributable to service. 2. A back disability was not manifest in service or within one year of separation. 3. A back disability was not caused or aggravated by the Veteran's left ankle disability. 4. A right foot disability was not manifest in service. A right foot disability is not attributable to service. 5. A right foot disability was not caused or aggravated by the Veteran's left ankle and back disabilities. 6. Bilateral hearing loss is attributable to service. CONCLUSIONS OF LAW 1. Chronic left ankle pain was incurred in service. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 2. A back disability was not incurred in or aggravated by service, arthritis may not be presumed to have been incurred therein, and was not proximately due to, the result of, or aggravated by the Veteran's left ankle disability. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 3. A right foot disability was not incurred in or aggravated by service, and was not proximately due to, the result of, or aggravated by the Veteran's left ankle or back disabilities. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). 4. Bilateral hearing loss was incurred in service. 38 U.S.C. §§ 1110, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.385, 4.85 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has met all statutory and regulatory notice and duty to assist provisions with respect to the Veteran's claims. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2016). Additionally, the Veteran has not 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 duty to assist argument). The Board finds the duties to notify and assist have been met, all due process concerns have been satisfied, and the appeal may be considered on the merits. II. Finality of Service Connection Claims VA denied the Veteran's claim for service connection for the left and right ankles in in a February 2007 rating decision. In January and early February 2008, the Veteran submitted additional new and material evidence including photographs of his left ankle and private treatment records for both ankles. Therefore, the February 2007 decision was not final. In November 2008, the RO denied service connection for back pain, hearing loss, and a right foot disorder. The Veteran expressed timely disagreement within one year in November 2009. Therefore, the November 2008 decision was not final. III. Service Connection To establish service connection a Veteran must generally show: "(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." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established for arthritis manifesting to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. 3.307, 3.309(a). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Arthritis qualifies as one of these listed conditions. Arthritis is subject to presumptive service connection and can be proven alternatively by showing continuous symptomatology. Except as provided in §3.300(c), disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310. The evidence must show: (1) that a current disability exists; and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated (permanently worsened in severity beyond its natural progress) by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448-49 (1995). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C.A. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). IV. History and Analysis A. Chronic Left Ankle Pain The Veteran served as a U.S. Marine Corps Reserve armorer and was mobilized in 2003 for duty in California. The Veteran contends that he injured his left ankle in martial arts training in this service. During the Board hearing, the Veteran reported that he experienced severe swelling for several days and was required to return to training without crutches even though he could not tie the shoelaces of his boot. While on active duty in April 2003, the Veteran sought treatment for left ankle and shin pain that he experience one week earlier in martial arts training. A clinician noted swelling and bruising but X-rays were normal. (In January 2008, the Veteran submitted a photograph of his ankle taken two days after the injury showing some swelling of an area on the outer side of the ankle.) The clinician diagnosed a resolving ankle sprain and contusion of the left fibula and prescribed anti-inflammatory medication, warm compresses, and stretching exercises. The Veteran returned to duty and successfully completed a higher level of martial arts training in May 2003. He received physical therapy in September 2003. The therapist noted that the Veteran reported some foot tingling occasionally while performing three to five mile runs, but no edema was observed during the treatment. In March 2004 demobilization questionnaire, he reported the history of the ankle injury and continued occasional pain, but acknowledged that he had no disabilities that would disqualify him from further performance of duty. The Veteran sought treatment from a private physician while still on active duty in February 2004. The physician summarized the history from the Veteran's reports and noted current symptoms of periodic pain and swelling of the left ankle when walking on uneven ground. The physician noted no swelling or laxity, a normal range of motion, and normal gait. Concurrent X-rays were normal. The physician diagnosed a slow to resolve ankle sprain. The Veteran submitted a statement from another private physician dated in July 2010. The physician noted that he had examined the Veteran the previous April and June and diagnosed meralgia paresthetica and chronic ankle pain. He noted that the chronic ankle pain was more likely than not related to the severe sprain in service with no further explanation. Treatment records from a private primary care physician from 2009 to 2012 show on-going reports of left ankle and heel discomfort but normal ranges of motion. Foot pain was diagnosed as plantar fasciitis. There were no recommendations for medical intervention. The Veteran was afforded a December 2012 VA examination of his left ankle. The examiner noted a review of the claims file and the history of a sprain and contusion to the ankle and lower leg while in service in 2003. The Veteran reported pain in the left ankle and numbness and tingling in the left leg, use of an ankle brace, and use of anti-inflammatory medication. Range of motion and a concurrent X-ray were normal for age. The physician found that the injury was acute because the Veteran returned to duty with no follow-up evaluation and because the injury noted in service would not result in long-term chronic conditions. The VA examiner opined that this is more likely than not associated with a condition affecting a peripheral nerve and less likely than not associated with an acute ankle injury. The VA examiner concluded that based on a review of the Veteran's service treatment records, his personal history and clinical experience and expertise, the Veteran's left ankle condition was less likely than incurred in or caused by his left ankle injury suffered in April 2003. The Veteran testified in June 2017 regarding his in service ankle injury during Marine Corps martial arts training. He testified that he was hit in the ankle by his sparring partner. He reported that he currently has pain in the ankle with complaints of numbness and tingling in the left leg including when he lies on the left leg at night. He denied surgery on the ankle. He wears an ankle brace at times and treats the symptoms with ibuprofen both of which provide some symptom relief. The Veteran submitted a 2017 private medical opinion from his primary care physician. The doctor opined that "After reviewing his medical history, it is my medical opinion that his chronic left ankle pain is a direct result of the injury sustained while on active military duty." There was no explanation or rationale. The Veteran is competent to report pain in his ankle. He is competent to report that he was injured in service. He is competent to report what he has been told by his primary care physician and other doctors regarding his left ankle disability. The Board finds these reports credible. Here, the Veteran's testimony, STRs, and private medical opinion all demonstrate that the Veteran sustained an ankle injury in service. He has credibly reported a continuity of pain since the injury. The clinical evaluation of the pain has been limited to a slowing resolving ankle sprain for over 13 years or a possible peripheral nerve abnormality. The VA examiner found the injury to be acute and correctly noted that the Veteran was treated once and continued to perform his Marine duties for the remainder of his tour including successfully completing an advanced martial arts course. On the other hand, his private physician attributed the current disorder to the injury but with no explanation or rationale. Notably, the physicians never engaged in further imaging studies or intervention to treat the disorder. Resolving all doubt in favor of the Veteran, the Board finds that the evidence is at least in equipoise regarding whether the left ankle sprain in service caused the Veteran's current chronic left ankle pain or that the ankle sprain did not resolve since the injury and continued to the present. Therefore, service connection is warranted. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). B. Back Disability The Veteran contended during the Board hearing that he developed a low back disorder because he shifted weight from the left ankle to the right that caused strain on his back. In written statements, the Veteran reports that he has back pain on a regular basis about 2 to 3 times per year. He gets bad spasms in the low back primarily on the left which requires treatment with heat, massage, muscle relaxants and anti-inflammatory medications and rest. He reports the symptoms last for 5 to 6 days. He denies injury or trauma to the back and has had no surgery. Marine Reserve records contain a December 2002 periodic examination which was clinically normal for the spine and other musculoskeletal areas. An April 2004 Report of Medical History indicates the Veteran denied arthritis, rheumatism, or bursitis. He also denied recurrent back pain or any back problem. As noted above, while on active duty, the Veteran completed two martial arts courses. In January 2005, the Veteran underwent an ultrasound examination of the lower back that identified a small lipoma. There are no concurrent clinical evaluations, diagnoses, or records of treatment. A January 2009 private primary care treatment record indicates the Veteran was negative for arthralgia, back pain, and myalgia. In February 2009, the physician noted a normal gait. In April 2010, the physician performed a back examination noting no abnormalities but investigated the Veteran's reports of tingling in the lower leg for the past year. In June 2010, the physician noted the Veteran's report of low back pain for the past week that he found to be an acute problem with no previous history of back pain. The physician obtained a magnetic resonance image that showed disc bulging at three levels and mild to moderate lumbar spondylosis In a July 2010 statement, another private physician noted that he had treated the Veteran the previous April and June for low back pain. The physician noted that low back pain "may be an indirect result of the [left ankle] injury but the meralgia paresthetica low back pain are less likely than not service-connected." Notably, subsequent records of care by the primary care physician through 2012 are generally silent for continued back symptoms or any treatment or intervention. On one occasion in May 2011, the Veteran reported that he had been working out at a gym but experienced the onset of an episode of back pain after twisting but not while working out. The Veteran was afforded a VA examination of his back with X-rays in December 2012. No fractures or dislocations are demonstrated. The bones and soft tissues were within normal limits for his age. No significant degenerative changes were identified. The VA examiner opined that his lumbar spine series within normal limits for age. The Veteran testified in in June 2017 that his left ankle disability causes him to lean, putting all of the pressure on his back. In a September 2017 letter, the primary care physician cited the June 2010 lumbar MRI. The physician opined that the Veteran's back pain was not likely a direct injury but more likely than not an indirect consequence of his left ankle injury due to altered weight-bearing and asymmetric gait and compensatory mechanisms caused by the original service connected ankle injury which have contributed to the abnormal stress on these other structures. Of note, the physician also referred to right foot disorders and treatment and did not indicate why the altered weight bearing and abnormal gait were not mentioned in any of his clinical records. The Board finds that service connection for a low back disorder, identified by imaging studies in 2010 as bulging discs and mild to moderate spondylosis is not warranted. The Board considered the Veteran's lay contentions that the disorder was caused by weight shifting away from the left ankle because of pain. Although the Veteran is competent to report weight shifting, he is not competent to determine the origin of his spinal disease. Moreover, his lay statements warrant less probative weight because he also experiences right foot discomfort (discussed in more detail below) and because this was not reported or evaluated by his primary care physician over several years of treatment. The Board also assigns less probative weight to the primary care physician's recent conclusions regarding weight shifting because it was not mentioned in his clinician records and because the back pain was noted to be acute on several occasions and that the spinal deficits developed in 2010 over a relatively short time interval. Here, the most probative evidence is the STRs that are entirely silent for low back manifestations and December 2012 VA examination indicating the Veteran's back disability first manifest many years after discharge. The first pathology for back pain was confirmed by imaging June of 2010, several years removed from discharge. In addition, the Veteran did not have the characteristic manifestations in service to identify a chronic disease identity. Consequently, service connection on a direct basis must be denied. The Board further finds that the most probative medical evidence of record regarding secondary service connection for a back disability is the December 2012 VA examination. The physician stated that the back was within normal limits. The private physician's assertions regarding June 2010 findings from a lumbar MRI are inconsistent with the STRs and April 2010 private examination and December 2012 VA examination. The Board finds that the private physician's assertions based upon this evidence are inconsistent with the private treatment records, and therefore finds it warrants less probative weight. Additionally, an arthritic condition of the back was not identified for several years after service, and the clinical records are silent for abnormal gait or weight shifting notwithstanding the physician's conclusion in the 2017 letter. Therefore, the most probative medical evidence indicates that the Veteran is not entitled to service connection for a back disability on a secondary basis. 38 C.F.R. § 3.310. In reaching this conclusion, the Board finds that the preponderance of the evidence is against this claim. As such, the benefit of the doubt rule is not for application, and the claim must be denied. 38 U.S.C.A. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). C. Right Foot Disability The Veteran's December 2002 enlistment examination was clinically normal for the lower extremities. In an April 2003 Report of Medical History, the Veteran reported impaired use of arms legs hands or feet. However, service connection is being granted for his left ankle, and the Veteran did not specify the feet or foot experiencing impairment. An undated annual certificate of physical condition references a contemporaneous 2004 dental examination with a history notation of a bunion on the right foot and the right heel. It indicates the Veteran was seeking follow up treatment for this. A private treatment record from March 2004 from Waco, Texas indicates the Veteran sought treatment for a right foot disability. However, it also contains disability certificate from a day later indicating the Veteran had sufficiently recovered. June 2011 private treatment records indicate the Veteran presented with a history of right ankle pain. It does not radiate. The Veteran had started wearing an insert just in that one shoe and it has seemed to help. He wondered if he had maybe put more pressure on the right leg since his left leg has chronic pain. He reported that his right ankle had also started popping. An April 2012 private treatment record indicates the Veteran had left foot pain. It does note right foot pain in conjunction with this notation. The Veteran was afforded a VA examination in December 2012. Imaging revealed no fractures or dislocations. The bones and soft tissues were within normal limits for age. He had minimal plantar calcaneal spurs present. The physician opined that the right foot was within normal limits for his age. The Veteran testified in in June 2017 that his left ankle disability causes him to lean onto his right ankle, causing it to hurt and pop louder. The 2017 private medical opinion concluded that the Veteran's right plantar fasciitis was not likely a direct result of his injury, but it is more likely than not an indirect consequence of his left ankle injury. The Veteran is competent to report pain in his right foot. He is competent to report it popping more frequently. Here, the most probative evidence is the STRs and December 2012 VA examination indicating the Veteran's right foot disability first manifested many years from discharge. The Board acknowledges the Veteran's lay statements regarding a right foot injury and popping. June 2011 private treatment records indicate that his ankle had then started popping. However, at his June 2017 hearing, he described this as related to overcompensating for his left ankle injury, which would put the onset several years earlier than June 2011. In this case, such reports are inconsistent with the Veteran's other statements indicating a continuity of right foot symptomatology since his active service and further damage the credibility of the Veteran's reports as to the onset of such symptoms. The Veteran's lay testimony warrant less probative weight when compared to the STRs and December 2012 VA medical examination results. Consequently, service connection for a right foot disability is not warranted. The Board further finds that the most probative medical evidence of record regarding secondary service connection for a right foot disability is the December 2012 VA examination. The physician stated that the foot was within normal limits. The private physician's assertions are inconsistent with the STRs and June 2011 private treatment records, indicating the right foot was clinically normal. The March 2004 private treatment record indicates the foot had recovered. The Board therefore finds that the private physician's assertions based upon this evidence are inconsistent with the private treatment records, and thus finds it to lack credibility. Consequently, the Veteran is not entitled to service connection for a back disability on a secondary basis. 38 C.F.R. § 3.310. In reaching this conclusion, the Board finds that the preponderance of the evidence is against this claim. As such, the benefit of the doubt rule is not for application, and the claim must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). D. Bilateral Hearing Loss The Veteran contends that his service-connected bilateral hearing loss was caused by exposure to high levels of noise on weapons training ranges and in weapons repair facilities. In addition to the criteria for service connection provided above, the following is applicable to claims for service connection for hearing loss. Under the applicable criteria disability ratings are determined by a mechanical application of the rating schedule to the numeric designations assigned after audiometric evaluations are performed. See Lendenmann v. Principi, 3 Vet. App. 345, 349 (1992). Hearing loss disability evaluations range from 0 percent to 100 percent based on organic impairment of hearing acuity, as measured by controlled speech discrimination tests in conjunction with the average hearing threshold, as measured by puretone audiometric tests in the frequencies 1000, 2000, 3000 and 4000 Hertz. The rating schedule establishes 11 auditory acuity levels designated from Level I for essentially normal hearing acuity, through Level XI for profound deafness. VA audiometric examinations are conducted using a controlled speech discrimination test together with the results of a puretone audiometry test. The vertical lines in Table VI represent nine categories of the percentage of discrimination based on the controlled speech discrimination test. See 38 C.F.R. § 4.85. The horizontal columns in Table VI represent nine categories of decibel loss based on the pure tone audiometry test. The numeric designation of impaired hearing (Levels I through XI) is determined for each ear by intersecting the vertical row appropriate for the percentage of discrimination and the horizontal column appropriate to the puretone decibel loss. The percentage evaluation is found from Table VII by intersecting the vertical column appropriate for the numeric designation for the ear having the better hearing acuity and the horizontal row appropriate to the numeric designation level for the ear having the poorer hearing acuity. For example, if the better ear has a numeric designation Level V and the poorer ear has a numeric designation Level VII, the percentage evaluation is 30 percent. See 38 C.F.R. § 4.85. The threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). 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, 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 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. The Veteran's December 2002 military examination was clinically normal for the ears. In an April 2003 Report of Medical History, the Veteran also denied hearing loss or wearing a hearing aid, and ear trouble. An audiogram obtained in February 2007 while the Veteran was serving in the Marine Corps Reserve was clinically normal. An October 2012 VA audiometric examination revealed the Veteran had clinically normal hearing for VA purposes. Puretone thresholds were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 10 15 10 LEFT 10 5 10 10 10 Speech discrimination scores were 94 percent for each ear. The VA examiner rendered an opinion that the Veteran's claimed hearing loss was less likely than not related to noise exposure in service. The audiologist acknowledged the Veterans and his spouse's reports of difficulty hearing conversation and raising the volume on television. The audiologist also noted records of private primary care that were silent for any organic ear problems or loss of hearing acuity. The main basis for the audiologist's finding was the normal audiometric examination results including on this examination. The Veteran was most recently submitted private treatment records from a June 2017 audiometric examination. On the authorized audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 15 20 20 LEFT 25 20 30 30 30 Speech audiometry revealed speech recognition ability of 88 percent in the right ear and of 80 percent in the left ear. The audiologist identified mild high frequency bilaterally, with chronic and constant tinnitus. The Board finds that these audiometric results meet the definition of hearing loss as defined by VA. 38 C.F.R. § 3.385. In September 2017 the private audiologist rendered a medical opinion. After reviewing the service records, the she opined that it was at least as likely as not that that the Veteran's his hearing loss was caused by or contributed to by noise exposure during his military service. She based her opinion on the fact that the Veteran was exposed to excessive noise levels while in the military without benefit of adequate hearing protection, that his job duties had a high probability of noise exposure. She explained that he was exposed to excessive noise levels from gun fire, saws, air compressors and hammers while performing his job duties as a small arms repairman and a range safety advisor. His job duties had a high probability of noise exposure. In addition, she cited his lay statements that his tinnitus began while in service. The Veteran testified that he was in June 2017 that he was on the rifle range in the Marine Corps exposed to small arms fire, pistols. He was also exposed to hand grenades and everything else that goes along with training in the Marine Corps. The Veteran is competent to report difficulty hearing and ringing in his ears. The Board finds these reports credible. Here, there is a relatively equal balance of evidence both for and against service connection for bilateral hearing loss. The Veteran had normal hearing throughout his Marine Reserve service as shown in the February 2007 testing. Normal hearing was also measured in 2012. However, the most recent testing that showed speech discrimination scores less than 94 percent bilaterally met the VA criteria for disability. Regarding the cause of the current hearing loss, the most probative evidence is the recent June 2017 audiometric examination and September 2017 medical opinion. Both are consistent with the Veteran's June 2017 testimony and his exposure in service. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. §§ 5107; 38 C.F.R. §§ 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Consequently, service connection for bilateral hearing loss is warranted. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). ORDER Service connection for chronic left ankle pain is granted. Service connection for a back disability, to include as secondary to a left ankle disability, is denied. Service connection for a right foot disability, to include as secondary to service connected disabilities, is denied. Service connection for bilateral hearing loss is granted. ____________________________________________ J. W. FRANCIS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs