Citation Nr: 1754797 Decision Date: 11/30/17 Archive Date: 12/07/17 DOCKET NO. 13-34 263 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to a rating in excess of 10 percent for service-connected chronic lumbar spine strain. 2. Entitlement to service connection for a neck disability. 3. Entitlement to service connection for a left ear disability. 4. Entitlement to service connection for a left eye disability. 5. Entitlement to service connection for a left lower extremity disability. 6. Entitlement to service connection for a right lower extremity disability. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. K. Buckley, Counsel INTRODUCTION The Veteran served on active duty from March 1980 to July 1980 and November 1983 to June 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions dated June 2011 and February 2012 of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The Veteran was scheduled to appear at the San Diego RO to have a videoconference hearing with a Veterans Law Judge. She failed to appear for said hearing, and he has not since asked for it to be rescheduled. Accordingly, the hearing request is deemed withdrawn. See 38 C.F.R. § 20.704(d) (2017). The issues of entitlement to service connection for disabilities of the right and left lower extremities are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). The Veteran will be notified if further action on her part is required. FINDINGS OF FACT 1. Throughout the appeal period, the service-connected chronic lumbar strain has been manifested by pain and limitation of motion with forward flexion of the thoracolumbar spine limited to no more than 70 degrees with mild muscle spasms and reports of flare-ups with pain and stiffness; there was also no competent evidence of incapacitating episodes of intervertebral disc syndrome requiring prescribed bed rest. 2. A neck disability did not have its onset in service, did not manifest within the one year presumptive period, and is not otherwise related to the Veteran's active military service. 3. A left ear disability did not have its onset in service and is not otherwise related to the Veteran's active military service; the Veteran does not have left ear hearing loss for VA compensation purposes. 4. A left eye disability did not have its onset in service and is not otherwise related to the Veteran's active military service. CONCLUSIONS OF LAW 1. The criteria for a disability rating of 20 percent, but no higher, for service-connected chronic lumbar strain have been met throughout the appeal period. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. § 4.71a, Diagnostic Code 5237 (2017). 2. A neck disability was not incurred in or aggravated by the Veteran's military service, and may not be presumed to have been so incurred. 38 U.S.C. §§ 101, 1101, 1110, 1112, 1113, 1116, 5107 (2012); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.307, 3.309 (2017). 3. A left ear disability was not incurred in or aggravated by the Veteran's military service, and may not be presumed to have been so incurred. 38 U.S.C. §§ 1110, 1112, 1113, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2017). 4. A left eye disability was not incurred in or aggravated by the Veteran's military service. 38 U.S.C. §§ 101, 1101, 1110, 1112, 1113, 1116, 5107 (2012); 38 C.F.R. §§ 3.6, 3.102, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and to Assist Neither the Veteran nor her 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). Thus, the Board finds that VA does not have a duty to assist that was unmet. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011). II. Schedular rating claim Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.10. Where there is a question as to which of two ratings should be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are also appropriate in any increased rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, analysis in this decision has therefore been undertaken with consideration of the possibility that different ratings may be warranted for different time periods as to the pending claim. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage and the functional loss with respect to all of these elements. In evaluating disabilities of the musculoskeletal system, it is necessary to consider, along with the schedular criteria, functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. DeLuca v. Brown, 8 Vet. App. 202 (1995). Functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective enervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. The Court has held that VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss under 38 C.F.R. § 4.40, which requires VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. See DeLuca v. Brown, 8 Vet. App. 202 (1995). In Mitchell v. Shinseki, 25 Vet. App. 32 (2011), the Court held that, although pain may cause a functional loss, "pain itself does not rise to the level of functional loss as contemplated by VA regulations applicable to the musculoskeletal system." Rather, pain may result in functional loss, but only if it limits the ability "to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance." Id., quoting 38 C.F.R. § 4.40. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, actually painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint. The joints should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint. 38 C.F.R. § 4.59. In Burton v. Shinseki, 25 Vet. App. 1, 5 (2011), the Court found that, when 38 C.F.R. § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis context, the Board should address its applicability. Historically, in a January 1990 rating decision, the Veteran was service connected for fibromyalgia of the trunk, low back, and lower extremities at 10 percent from June 28, 1988. In November 2010, the Veteran asserted entitlement to an increased rating for her service-connected back disability. In the development of the increased rating claim, the Veteran was afforded a VA examination in January 2011 at which time the examiner determined that the Veteran did not suffer from fibromyalgia syndrome, but rather the proper diagnosis was chronic lumbosacral strain. Accordingly, in a June 2011 rating decision, the rating was corrected to chronic lumbar strain (previously rated as fibromyalgia) and the formerly established 10 percent rating was continued. The Veteran disagreed with the assigned rating and this appeal followed. Notably, the Veteran has not expressed disagreement with the assigned diagnostic code or the corrected diagnosis. Rather, she has asserted that her lumbar spine symptomatology is worse than is contemplated under the currently assigned rating. See the notice of disagreement (NOD) dated July 2011. The Veteran's lumbar spine disability is currently rated under 38 C.F.R. §§ 4.71a, DC 5237 (lumbosacral strain), which permits rating under either the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever results in the higher rating when all disabilities are combined. 38 C.F.R. § 4.71a. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent evaluation is warranted for incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent evaluation is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least four weeks, but less than six weeks during the past 12 months; and a 60 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a. An "incapacitating episode" for purposes of totaling the cumulative time is defined as "period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician." 38 C.F.R. § 4.71a, DC 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note 1. Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain, stiffness, or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply. A 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees, but not greater than 60 degrees; or, the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or, muscle spasms or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted when forward flexion of the thoracolumbar spine is 30 degrees or less or with favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a. Following the criteria, Note (1) provides: evaluate any associated objective neurologic abnormalities, including, but not limited to, bowel or bladder impairment, separately, under an appropriate diagnostic code. Note (2) provides that, for VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. Note (3) provides that in exceptional cases, an examiner may state that because of age, body habitus, neurologic disease, or other factors not the result of disease or injury of the spine, the range of motion of the spine in a particular individual should be considered normal for that individual, even though it does not conform to the normal range of motion stated in Note (2). Provided that the examiner supplies an explanation, the examiner's assessment that the range of motion is normal for that individual will be accepted. Note (4) requires that each range of motion measurement be rounded to the nearest five degrees. Note (5) provides that for VA compensation purposes, unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Note (6) provides that disabilities of the thoracolumbar and cervical spine segments must be separately evaluated, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. In this case, the general rating formula for diseases and injuries of the spine is appropriate in that the medical evidence of record indicates that the Veteran's service-connected lumbar spine disability is primarily manifested by pain, spasm, and loss of motion, which is congruent with the criteria set out in the general rating formula for diseases and injuries of the spine. The Veteran has not argued otherwise. Here, the Veteran filed a claim of entitlement to an increased rating for her lumbar spine disability in November 2010, at which time she reported that her symptoms had worsened. The Veteran was afforded a VA examination in January 2011 at which time she denied generalized joint pain, but endorsed low back pain. She described chronic daily mild low back pain with intermittent and incapacitating flares which occur infrequently. The Veteran reported that these incapacitating flares require bed rest for one to two days and occur less than once per year. She manages her symptoms with yoga, stretching, and massage. She was able to work as a surgical operating room technician until leaving her job in 2008 for reasons unrelated to her back disability. She sleeps with several back support pillows. The examiner did not identify fatigue or weakness in the Veteran's lumbar spine. There was decreased motion and stiffness. The Veteran's gait was normal, and there was no evidence of ankylosis. Range of motion testing revealed flexion to 70 degrees, extension to 15 degrees, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 20 degrees. There was objective evidence of pain on motion. Repetitive motion testing did not yield additional limitation of motion. Examination of the lower extremities demonstrated normal reflexes; muscle strength was intact. There was no evidence of atrophy. The examiner noted mild tenderness to palpation and mild spasm of the Veteran's lower lumbar paraspinal muscles. The examiner confirmed a diagnosis of chronic lumbar strain. VA treatment records dated in April 2011 and June 2011 documented the Veteran's report of chronic back pain. The Veteran was afforded another VA examination in March 2014 at which time she reported continuing flare-ups manifested by pain and stiffness. Range of motion testing showed flexion to 80 degrees with pain, extension to 20 degrees with pain, right and left lateral flexion to 30 degrees, and right and left lateral rotation to 30 degrees. There was no additional limitation of motion on repetitive use testing. The examiner indicated there was no localized tenderness, guarding, or muscle spasm of the lumbar spine. The Veteran's muscle strength was intact. Deep tendon reflexes and sensory examination were intact. The examiner reported that there was no indication of intervertebral disc syndrome (IVDS). The Veteran does not use any assistive devices for ambulation. The examiner stated that the Veteran's chronic lumbar spine strain does not impact her ability to work. The examiner reported that the Veteran has point tenderness on palpation of her coccyx. The Veteran's gait and posture were normal. The examiner opined, "[t]here are contributing factors of pain, weakness, fatigability and/or incoordination and there is additional limitation of functional ability of the thoracolumbar spine during flare-ups or repeated use over time, decreased capacity for prolonged standing, walking, climbing, [or] lifting." He confirmed a continuing diagnosis of chronic lumbar strain. The Board has considered whether a schedular rating in excess of 10 percent is warranted for the Veteran's lumbar spine disability, based on functional loss due to pain, weakness, excess fatigability, incoordination and flare-ups, pursuant to 38 C.F.R. §§ 4.40, 4.45, and 4.59 and the Court's holding in DeLuca v. Brown, supra. Applying the facts in this case to the criteria set forth above, the Board finds that a disability rating of 20 percent is warranted. The January 2011 VA examiner documented forward flexion of the lumbar spine to 70 degrees; however, the examiner additionally noted that there was objective evidence of pain and muscle spasm. In addition, the March 2014 VA examiner reported that "[t]here are contributing factors of pain, weakness, fatigability and/or incoordination and there is additional limitation of functional ability of the thoracolumbar spine during flare-ups or repeated use over time with decreased capacity for prolonged standing, walking, climbing, and lifting." Moreover, the Veteran described symptoms of flare-ups with pain and stiffness. See the VA examination reports dated January 2011 and March 2014. As such, the Board finds that the Veteran's service-connected lumbar spine disability more nearly approximates the criteria for a 20 percent disability rating. See 38 C.F.R. §§ 4.7, 4.71a (2017). However, a rating in excess of 20 percent is not warranted at any time during the appeal period. As described above, the documented range of motion measurements were well above the limitation prescribed by the pertinent diagnostic code to warrant a 40 percent disability rating (specifically, forward flexion of the thoracolumbar spine to 30 degrees or less). See 38 C.F.R. § 4.71a, DC 5237. Moreover, no ankylosis, either favorable or unfavorable, was shown during the appeal period. Thus, there is no other objective evidence demonstrating greater impairment of range of motion of the lumbar spine. As noted above, the Board recognizes the Veteran's report of significant exacerbations of pain with flare-ups. These symptoms were considered by the Board in granting a 20 percent evaluation. Critically, there is no evidence to corroborate additional functional limitations such as would warrant an evaluation in excess of 20 percent. While the Board is required to consider the effect of the Veteran's pain when making a rating determination, and has done so in this case, the Rating Schedule does not provide for a separate rating for pain. Rather, it provides guidance for determining ratings under other diagnostic codes assessing musculoskeletal function. Spurgeon v. Brown, 10 Vet. App. 194 (1997). In this case, the Veteran is already being adequately compensated for pain and the resulting functional loss. Therefore, a rating in excess of 20 percent is not warranted under the schedular criteria. The Board recognizes that the Veteran asserted that she suffers from incapacitating episodes several times per year due to her lumbar spine symptomatology. Notably, however, neither VA examiner determined that she suffered from IVDS. These findings are consistent with the Veteran's treatment records, which do not document IVDS or incapacitating episodes with periods of bed rest prescribed by a physician. As such, a rating under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes would not afford the Veteran, as she does not exhibit incapacitating episodes as defined in the applicable schedular criteria. Additionally, as indicated above, Note 1 of the General Rating Formula for Disease and Injuries of the Spine instructs to evaluate any associated objective neurologic abnormalities separately, under an appropriate Diagnostic Code. As will be described below, the matters of entitlement to service connection for disabilities of the right and left lower extremities are being remanded below. There is no evidence to suggest, nor has the Veteran endorsed, any other neurological manifestations due to her lumbar spine disability. While there may have been day-to-day fluctuations in the manifestations of the Veteran's service-connected lumbar spine disability, the evidence shows no distinct periods of time during the appeal period, when her disability varied to such an extent that a rating greater or less than 20 percent assigned herein would be warranted. Hart, supra. Accordingly, the preponderance of the evidence shows that the Veteran's chronic lumbar strain warrants a rating of 20 percent, but no higher, throughout the appeal period. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. Neither the Veteran nor her 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, 369-70 (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). III. Service connection In order to prevail on the issue of service connection for any particular disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, including arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from active service. 38 U.S.C. § 1112 (2012); 38 C.F.R. §§ 3.307, 3.309 (2017). The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (rejecting the argument that continuity of symptomatology in § 3.303(b) has any role other than to afford an alternative route to service connection for specific chronic diseases). In addition, service connection may be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2017). VA also deems sensorineural hearing loss to be an organic disease of the nervous system for purposes of 38 C.F.R. § 3.309(a). See Veterans Benefits Administration (VBA) Fast Letter 10-02 (Mar. 18, 2010); Memorandum, Characterization of High Frequency Sensorineural Hearing Loss, Under Secretary for Health, October 4, 1995. Although the Walker case did not expressly address this issue, the Board will deem sensorineural hearing loss as a "chronic" disease for purposes of this decision. The Board must assess the credibility and weight of all the 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. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. a. Neck disability In this matter, the Veteran contends that she developed a neck disability as a result of a motor vehicle accident during her military service. On review of the record, the Board finds that the preponderance of the evidence is against the claim. The Veteran served on active duty from March 1980 to July 1980 and from November 1983 to June 1988. Her service treatment records (STRs) confirm that she was involved in a head-on motor vehicle accident (MVA) in August 1987. Immediately following the accident, she was placed on a cervical spine board and complained of neck pain. See the STRs dated August 1987. In December 1987, it was noted that the Veteran suffered a cervical strain. In a March 1988 Medical Board examination, it was noted that the Veteran was diagnosed with fibromyalgia syndrome affecting her low back, trunk and lower extremities, status-post cerebral contusion, anemia, and mild obstructive lung disease. It was further noted that the Veteran reported dysesthesias of the neck and back. In an August 1988 VA examination report, the Veteran reported shooting pain from her neck; however, a neck disability was not identified at that time. Similarly, in a November 1989 VA examination, the Veteran's report of right side of neck pain was noted. A contemporaneous x-ray revealed a shallow cervical dorsal scoliosis. The Veteran was afforded a VA examination in October 2012, at which time the examiner diagnosed her with cervical spine strain with mild degenerative changes. The examiner noted that, following the 1987 in-service MVA, the Veteran fell down a flight of stairs in May 2011 and another fall in August 2012. As to the question of nexus, the examiner determined, "[g]iven subjective information, documentation, and objective findings, it is this examiner's opinion that this is less likely as not caused by or a result of active service." The examiner explained, "STRs do indicate complaints and treatment post-MVA. However, the medical board examination . . . does not diagnose the patient with a cervical spine condition, even though cervical spine was mentioned in the history. There is no nexus established since discharge from active service and the current complaints only started after the patient's fall in August 2012. The mild multi-level degenerative changes found on x-rays are age appropriate." When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). The United States Court of Appeals for Veterans Claims (Court) has held that claims file review, as it pertains to obtaining an overview of a claimant's medical history, is not a requirement for private medical opinions. A medical opinion that contains only data and conclusions is not entitled to any weight. Further a review of the claims file cannot compensate for lack of the reasoned analysis required in a medical opinion, which is where most of the probative value of a medical opinion comes from. "It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Significantly, the findings of the October 2012 VA examiner were thoroughly explained and fully supported by the evidence of record, as well as the pertinent medical literature. To this end, the Board notes that the October 2012 examiner's nexus opinion was based on a review of the record, including the lay statements and evidence submitted by the Veteran, and the examiner explained the reasons for his conclusions based on an accurate characterization of the evidence of record. His conclusion was also based on the character of the Veteran's current cervical spine pathology which the examiner explained, based on his medical training, was consistent with age. The Board therefore places significant weight on the findings of the October 2012 VA examiner. See Nieves-Rodriguez, supra; see also Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). Accordingly, the Board finds that the competent medical evidence demonstrating the absence of nexus between the claimed disability and the Veteran's active duty service outweighs any medical evidence suggestive of a nexus. The Board has carefully considered the contentions of the Veteran that the currently diagnosed cervical spine strain was incurred during her military service. To this end, the Board recognizes that lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Kahana, 24 Vet. App. at 433, n. 4. In this case, the Veteran's assertions as to etiology concern an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Cf. Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). See also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Questions of competency notwithstanding, the Veteran's lay theory regarding the etiology of her neck disability are contradicted by the conclusion of the October 2012 VA examiner who specifically considered the Veteran's lay statements in rendering his negative opinion. The Board finds the specific, reasoned opinion of the trained health care provider who conducted the October 2012 VA examination to be of greater probative weight than the more general lay assertions of the Veteran. The Board has considered that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan, supra. Crucially, however, the Veteran's contentions in support of service connection, including continuing post-service symptomatology of the currently diagnosed cervical spine disability are contradicted by the findings of the October 2012 VA examiner who specifically considered the lay assertions and any such inferences contained in the record in rendering the negative nexus opinion. Considering the overall evidence, including the post-service medical evidence, the October 2012 VA medical opinion, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In conclusion, the preponderance of the evidence is against the Veteran's claim that she suffers from a cervical spine disability, which is related to her military service. Thus, the benefit-of-the-doubt rule is not applicable to the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. b. Disabilities of the left ear and left eye Service connection for impaired hearing shall only be established when hearing status, as determined by audiometric testing, meets specified pure tone and speech recognition criteria. Audiometric testing measures threshold hearing levels (in decibels), over a range of frequencies (in Hertz). See Hensley v. Brown, 5 Vet. App. 155, 158 (1993). The determination of whether a veteran has a disability based on hearing loss is governed by 38 C.F.R. § 3.385. For the purposes of applying the law administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385 (2017). In this matter, the Veteran contends that she developed disabilities of her left ear and left eye during her military service. On review of the record, the Board finds that the preponderance of the evidence is against the claim. The Veteran has asserted that she injured her left ear and left eye due to a rifle misfire during boot camp. See the Veteran's claim dated November 2010. She indicated that she got gunpowder in her left eye, and sustained acoustic trauma to her left ear as a result of the incident. Id. To this end, following her initial period of active duty from March 1980 to July 1980, the Veteran filed a claim of entitlement to service connection for residuals of gunpowder injury to her right eye. She was afforded a VA examination in September 1980 at which time she reported occasional blurry vision and pain in her right eye. She did not complaint of a left eye injury at that time, nor did the examiner diagnose a left eye disability. STRs from the Veteran's second period of active duty service indicate that she complained of blurred vision and right eye pain. See the STR dated May 1985. However, her STRs are pertinently absent any complaints of or treatment for left eye symptomatology. Similarly, although STRs dated in April 1987 document the Veteran's report of muffled hearing in her right ear, there is no documentation of any left ear complaints. In a January 2011 statement, the Veteran reported that she was diagnosed with a retinal tear of her left eye with worsening vision in December 2010. To this end, VA treatment records dated in December 2010 note a possible retinal tear of the left eye with long standing photopia; meibomitis and myopic astigmatic presbyopia were also indicated. VA treatment records dated in January 2011 note the Veteran's report of eye irritation and pain; she was to be evaluated for a retinal tear. VA treatment records dated in June 2011 indicated that the Veteran endorsed vision complaints of white shadows and a feeling of 'something in' her left eye. VA treatment providers reported that these symptoms are consistent with dry eye and meibomitis. Separate June 2011 VA treatment records noted that the Veteran was seen by a private audiologist who determined that her hearing was within normal limits. VA treatment records dated in August 2012 indicated that the Veteran had left eye pain of uncertain etiology. In October 2012 VA treatment records, it was noted that the Veteran had visual complaints usually citing a feeling of something in her left eye, status-post rifle range incident. The Veteran was afforded a VA examination in October 2012 as to the left ear. She was not diagnosed with any left ear pathology; rather, the Veteran was diagnosed with peripheral vestibular disorder and vertigo. It was further noted that her mild episodic vertigo is likely secondary to traumatic brain injury (TBI) sustained in her 1987 in-service MVA. The Board notes that the Veteran was service-connected for TBI in an October 2016 rating decision. A VA audiology examination was conducted in March 2014, at which time audiometric testing demonstrated the following. HERTZ 500 1000 2000 3000 4000 LEFT 20 20 30 25 25 These auditory thresholds are insufficient to establish a hearing loss disability for VA compensation purposes. 38 C.F.R. § 3.385. Although the Veteran had a speech recognition score of 78 percent in the left ear, the examiner determined that "[t]he use of the speech discrimination score is not appropriate for the Veteran because of language difficulties, cognitive problems, inconsistent speech discrimination scores, etc., that make combined use of puretone average and speech discrimination scores inappropriate." As such, the findings of the March 2014 VA examination do not establish a left ear hearing loss disability sufficient for VA compensation purposes. 38 C.F.R. § 3.385. The Veteran was afforded a VA examination as to her claimed left eye disability in March 2014. The examiner noted the Veteran's report of bilateral eye dryness; the Veteran identified the onset of this dryness as 1980. She additionally reported that she experienced a left eye injury due to gunpowder striking her eye. She reported that, over the past several years, her left eye has developed a sometimes painful feeling of foreign object. Her corrected distance vision was 20/40 or better and her corrected near vision was also 20/40 or better. There was no decrease in visual acuity or other visual impairment. Examination of the eye showed heavier inferior punctuate staining of her corneas. The examiner reported that there was no pathology of the left eye upon which to render a diagnosis. The examiner further stated that the claimed left eye dryness and corneal staining was not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran reported the shooting range injury occurred in the left eye, but the record indicates that the injuries were only to the right eye. The examiner continued, "[s]he was able to be fitted comfortably and visually well with a contact lens in 1988, and enjoys good vision currently. The symptoms she has are due to eye dryness and there are characteristic surface changes of the eye that go along with that diagnosis." The Veteran was afforded another VA examination as to her claimed left ear disability in March 2014. The examiner noted that she does not have any left ear pathology upon which to render a diagnosis. Significantly, the findings of the March 2014 VA examiners were thoroughly explained and fully supported by a detailed review of the Veteran's medical history. To this end, the Board notes that the March 2014 medical opinions were further based on a review of the record, including the lay statements and evidence submitted by the Veteran, and the examiner explained the reasons for her conclusions based on an accurate characterization of the evidence of record. The Board therefore places significant weight on the findings of the March 2014 VA examiners. See Nieves-Rodriguez, supra; see also Bloom, supra. Accordingly, the Board finds that the competent medical evidence demonstrating the absence of nexus between the claimed left eye and left ear disabilities and the Veteran's active duty service outweighs any medical evidence suggestive of nexus. The Board has carefully considered the contentions of the Veteran that she suffers from disabilities of her left eye and left ear due to her military service. To this end, the Board recognizes that lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson; supra; Kahana, 24 Vet. App. at 433, n. 4. In this case, the Veteran's assertions as to diagnoses and etiology concern internal medical processes, which extend beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Cf. Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-9; Falzone, 8 Vet. App. at 403 (lay person competent to testify to pain and visible flatness of his feet); with Clemons, 23 Vet. App. at 6 ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert, 21 Vet. App. at 462 (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). See also Colantonio, 606 F.3d at 1382 (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). Questions of competency notwithstanding, the Veteran's lay theory regarding the diagnosis and etiology of her claimed disabilities are contradicted by the conclusion of the March 2014 VA examiners who specifically considered the Veteran's lay statements in rendering their negative opinions. The Board finds the specific, reasoned opinion of the trained health care providers who conducted the March 2014 VA examinations to be of greater probative weight than the more general lay assertions of the Veteran. Considering the overall evidence, including the post-service medical evidence, the March 2014 VA examination reports, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In conclusion, the preponderance of the evidence is against the Veteran's claim that she suffers from disabilities of the left eye and left ear, which are related to her military service. Thus, the benefit-of-the-doubt rule is not applicable to the claims. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. ORDER Entitlement to a rating of 20 percent, but no higher, for chronic lumbar spine strain is granted throughout the appeal period, subject to controlling regulations governing the payment of monetary awards. Entitlement to service connection for a neck disability is denied. Entitlement to service connection for a left ear disability is denied. Entitlement to service connection for a left eye disability is denied. REMAND The Veteran asserts entitlement to service connection for disabilities of the right and left lower extremities. For the reasons set forth below, the Board finds that these issues must be remanded for additional evidentiary development. VA treatment records document edema in the bilateral lower extremities, as well as complaints of pain, numbness, and tingling. See the VA treatment records dated August 2012. The Veteran was afforded a VA examination in August 2015 at which time she reported mild right lower extremity pain and severe left lower extremity. She also endorsed mild paresthesias/dysesthesias in the right lower extremity and severe paresthesias/dysesthesias in the left lower extremity. Mild numbness was reported in his right lower extremity and moderate numbness in the left lower extremity. Electromyographical (EMG) testing was not performed and the examiner did not address whether the Veteran had diagnosed disabilities of either lower extremity. Moreover, there is no medical opinion of record addressing whether the Veteran's claimed right and left lower extremity disabilities are due to her military service and/or caused or aggravated by her service-connected disabilities, to include her chronic lumbar spine strain. As such, the Board finds that this matter must be remanded in order to afford the Veteran with a new VA examination and medical opinion as to the claimed right and left lower extremity disabilities. Prior to arranging for the Veteran to undergo further VA examination, to ensure that all due process requirements are met, and that the record is complete, the AOJ should undertake appropriate action to obtain all pertinent, outstanding records. Accordingly, the case is REMANDED for the following action: 1. Obtain all outstanding records of VA evaluation and/or treatment of the Veteran since August 2016. Follow the procedures set forth in 38 C.F.R. § 3.159(c) with respect to requesting records from Federal facilities. All records/responses received should be associated with the claims file. 2. Schedule the Veteran for a VA examination to determine the etiology of her claimed right and left lower extremity disabilities. All indicated tests and studies should be conducted, to include EMG/nerve conduction testing if necessary. The contents of the electronic claims file must be made available to the examiner for review in connection with the examination. The examiner should either diagnose or rule-out disabilities of the right and left lower extremities. With respect to any diagnosed disability of the right or left lower extremity, the examiner should render an opinion, with supporting rationale, addressing whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the disability had its onset in service or is otherwise medically related to in-service injury or disease. The examiner should also provide an opinion as to whether it is at least as likely as not that any currently diagnosed right or left lower extremity disability was either (1) caused or (2) aggravated by the Veteran's service-connected disabilities, to include chronic lumbar spine strain. If aggravated, please specify the baseline of disability prior to aggravation, and the permanent, measurable increase in disability resulting from the aggravation. In addressing the above, the examiner should note that the absence of evidence of treatment for a claimed disability in the Veteran's service treatment records should not serve as the sole basis for a negative opinion. The examiner is also advised that the Veteran is competent to report her symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. 3. After conducting any additional development deemed necessary, the AOJ should readjudicate the claims, considering all the evidence of record. If the benefits sought are not granted, the Veteran and her representative should be furnished a Supplemental Statement of the Case and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ K. CONNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs