Citation Nr: 1721360 Decision Date: 06/13/17 Archive Date: 06/23/17 DOCKET NO. 13-18 552 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Whether new and material evidence has been submitted to reopen the claim of service connection for residuals, groin injury. 2. Entitlement to service connection for residuals, groin injury. 3. Entitlement to service connection for coronary artery disease, to include as due to herbicide exposure. 4. Entitlement to service connection for diabetes mellitus, type 2, to include as due to herbicide exposure. 5. Entitlement to service connection for a right knee disability. 6. Entitlement to service connection for bilateral hearing loss REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD R. Connally, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, had service from October 1964 to October 1968. This matter comes to the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. In an August 2010 rating decision, the RO denied service connection for bilateral hearing loss and residuals of a groin injury. The Veteran only submitted a Notice of Disagreement for the denial of service connection for bilateral hearing loss. In May 2013, a Statement of the Case was issued and the Veteran's substantive appeal was timely received in June 2013. In a May 2013 rating decision, the RO denied service connection for coronary artery disease, diabetes, a right knee injury, and whether new and material evidence was received for residuals, groin injury. The Veteran submitted a timely Notice of Disagreement for these four issues. A Statement of the Case was issued in November 2015 and the Veteran's substantive appeal was timely received in December 2015. In October 2016, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ); a transcript of the hearing is associated with the claims file. Additional evidence was received at the hearing and was accompanied by a waiver of RO consideration. See 38 C.F.R. § 20.1304(c)(2016). FINDINGS OF FACT 1. An August 2010 rating decision that denied service connection for residuals, groin injury was not appealed and the decision became final. 2. New and material evidence has been received since the August 2010 rating decision to substantiate the claim of entitlement to service connection for residuals, groin injury. The newly received evidence is neither cumulative nor redundant of evidence previously of record, and raises a reasonable possibility of substantiating the claim. 3. The Veteran has current residuals of the skin from a groin injury he incurred during service. 4. It is at least as likely as not that the Veteran was exposed to herbicide agents, including Agent Orange, while serving on active duty in Okinawa, Japan as airport security police at Kadena Air Force Base. 5. Many years after service, the Veteran was diagnosed with coronary artery disease and diabetes mellitus, type 2. 6. The Veteran's coronary artery disease and diabetes mellitus, type 2, are presumed as incurred in service as a result of herbicide agent exposure; that presumption is not adequately rebutted. 7. The Veteran has a current diagnosis for right knee arthritis and status post right knee arthroscopy. 8. The Veteran experienced an injury to the right knee during service. 9. Symptoms of the current right knee disability were continuous since service 10. The Veteran has a current diagnosis of bilateral hearing loss. 11. The Veteran was exposed to acoustic trauma during active service. 12. Symptoms of the currently diagnosed bilateral hearing loss have been continuous since service. CONCLUSIONS OF LAW 1. The August 2010 rating decision that denied the Veteran's claim of entitlement to service connection for residuals, groin injury is final. 38 U.S.C.A. § 7104 (West 2014); 38 C.F.R. §§ 3.104, 3.156, 20.302, 20.1103 (2016). 2. The criteria to reopen the service connection claim for residuals, groin injury have been met. 38 U.S.C.A. §§ 5103, 5103A, 5108 (West 2014); 38 C.F.R. § 3.156 (2016). 3. Resolving all reasonable doubt in favor of the Veteran, the criteria to establish service connection for residuals, groin injury have been met. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2016). 4. Resolving all reasonable doubt in favor of the Veteran, the criteria to establish service connection for coronary artery disease have been met. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2016). 5. Resolving all reasonable doubt in favor of the Veteran, the criteria to establish service connection for diabetes mellitus, type 2 have been met. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2016). 6. Resolving all reasonable doubt in favor of the Veteran, the criteria to establish service connection for a right knee disability have been met. 38 U.S.C.A. §§ 1101, 1110, 5103(a), 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2016). 7. Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for bilateral hearing loss have been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2016). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Claim to Reopen Service Connection The Veteran originally filed a claim for entitlement to service connection for residuals, groin injury in March 2010. Generally, a claim that has been denied may not thereafter be reopened and allowed based on the same record. 38 U.S.C.A. § 7105. However, pursuant to 38 U.S.C.A. § 5108, if new and material evidence is presented or secured with respect to a claim which has been disallowed, the VA Secretary shall reopen the claim and review the former disposition of the claim. New evidence is defined as existing evidence not previously submitted to agency decision makers. Material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2016). In determining whether evidence is "new and material," the credibility of the new evidence must be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Regardless of the RO's determination as to whether new and material evidence has been received, the Board has a jurisdictional responsibility to determine whether a claim previously denied by the RO is properly reopened. See Jackson v. Principi, 265 F.2d 1366 (Fed. Cir. 2001) (citing 38 U.S.C.A. §§ 5108, 7105(c)). Accordingly, the Board must initially determine whether there is new and material evidence to reopen a claim of service connection for major depression. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. The RO initially denied the claim in an August 2010 rating decision on the grounds that there was no evidence that the claimed condition occurred in or was caused by service. In this case, because new and material evidence had not been submitted within one year of the August 2010 rating decision, that rating decision became final because there was no new evidence to be considered. Contra Young v. Shinseki, 22 Vet. App. 461, 466 (2009)("When VA fails to consider new and material evidence submitted within the one-year appeal period pursuant to § 3.156(b), and that evidence establishes entitlement to the benefit sought, the underlying RO decision does not become final."); King v. Shinseki, 23 Vet. App. 464, 467 (2010)(Citing § 3.160(c), definition of pending claim, the CAVC held that if new and material evidence had been submitted but had not been acted upon, the Veteran's claim could still be pending until a decision had been made on that evidence). Since the August 2010 rating decision, documents have been associated with the claims file that discusses the possibility of verifying in-service incidents as well as a nexus for this disability. This evidence includes VA treatment records that show a current diagnosis for bilateral groin scar tissue and dermatitis. The Veteran has submitted a statement from his ex-wife that discusses his change in skin symptoms during their period of marriage when he was stationed in Okinawa, Japan. Moreover, an August 2016 Disability Benefits Questionnaire (received in October 2016), contains a VA physician's evaluation and opinion that the Veteran's skin symptoms on his groin area are related to service. The Veteran also testified before the undersigned in October 2016 as to the in-service events that caused his residual skin symptoms in his groin area that have continued to affect him since service. These VA treatment records, VA examination, supporting statements and documentation, coupled with the Veteran's testimony, contain facts that had not previously been associated with the file and discuss the presence of symptoms since service. As noted above, new and material evidence need not be received as to each previously unproven element of a claim in order to justify reopening thereof. See Shade v. Shinseki, 24 Vet. App. 110 (2010). In the present case, the Veteran has presented evidence that speaks directly to an element that was not of record, mainly in-service incidents and a possible nexus to a current disability. See Kent v. Nicholson, 20 Vet. App. 1, 10 (2006) (finding that "the question of what constitutes material evidence to reopen a claim for service connection depends on the basis on which the prior claim was denied"). Presumed credible, these documents represent evidence not previously submitted to agency decision makers that relates to an unestablished fact necessary to substantiate the claim. Thus, the Board finds that the additional evidence is new and material to reopen the claim of service connection for residuals, groin injury. Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. § 1110, 1131 (West 2014); 38 C.F.R. § 3.303(a) (2016). Service connection may 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). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as arthritis or an organic disease of the nervous system (including sensorineural hearing loss), to a degree of 10 percent or more within one year of separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. Arthritis and organic diseases of the nervous system, including sensorineural hearing loss, are "chronic diseases" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions of 38 C.F.R. § 3.303(b) based on "chronic" symptoms in service and "continuous" symptoms since service are applicable to the service connection claims for a right knee disability and bilateral hearing loss. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With a chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. For the showing of a chronic disease in service, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may be granted on a presumptive basis for certain diseases associated with exposure to certain herbicide agents, even though there is no record of such disease during service, if they manifest to a compensable degree any time after service, in a veteran who had active military, naval, or air service for at least 90 days, during the period beginning on January 9, 1962 and ending on May 7, 1975, in the Republic of Vietnam, including the waters offshore, and other locations if the conditions of service involved duty or visitation in Vietnam. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309(e), 3.313. This presumption may be rebutted by affirmative evidence to the contrary. 38 U.S.C.A. § 1113; 38 C.F.R. §§ 3.307, 3.309. The exclusive list of diseases which are covered by this presumption include the following: AL amyloidosis; chloracne or other acneform disease consistent with chloracne; type 2 diabetes (also known as Type II diabetes mellitus or adult-onset diabetes); Hodgkin's disease; Ischemic heart disease (including, but not limited to, acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina); all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia); multiple myeloma; non-Hodgkin's lymphoma; Parkinson's disease; acute and subacute peripheral neuropathy (meaning transient peripheral neuropathy that appears within weeks or months of exposure to an herbicide agent and resolves within two years of the date of onset); porphyria cutanea tarda; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). Accordingly, the Veteran's service connection claims for coronary artery disease and diabetes mellitus, type 2, will also be evaluated under this criteria. The Board has thoroughly reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; not every item of evidence has the same probative value. When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 2014); 38 C.F.R. § 3.102 (2016). The Court has held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. See Gilbert, 1 Vet. App. at 53. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Service Connection for Residuals, Groin Injury The Veteran contends that he developed a skin condition in his groin area due to service. Service treatment records do not reveal any skin abnormalities upon enlistment or discharge. However, in subsequent statements, the Veteran has detailed the etiology of his skin condition. See Correspondence, received October 2, 2013. He has explained that he developed a skin condition in his groin area due to constant skin irritation during service. He detailed the long work shifts as a security guard in hot, humid weather while stationed in Okinawa, Japan. He has stated that the daily irritation resulted in scar tissue forming in his groin area. He said that he treats this condition with over-the-counter ointments, creams, and powders, but that he continues to experience the same symptoms since service. The Veteran's ex-wife also submitted a statement in support of this claim. See Buddy/Lay Statement, received June 29, 2012. She said that she met the Veteran in 1967, and was married to him from 1968 to 1994. She witnessed the Veteran experience irritation to his groin area due to constant walking in warm, humid weather conditions during service. She saw him endure pain, itching, and saw thick scar tissue develop in close proximity to his scrotum due to irritation that caused his skin to crack open and bleed. She stated that the Veteran has followed a strict skin care regiment since she has known him, but that this condition has persisted nonetheless. The Veteran testified before the undersigned in October 2016 that he has continued to experience a skin condition in his groin area since he was stationed in Okinawa, Japan. He explained that he developed this condition in-service due to constant walking while on security patrols in hot, humid weather and that the rubbing of his fatigue pants against his groin area "caused [his] skin to erode" and that it eventually became "constant contact dermatitis." He also explained that he is a registered nurse on a medical surgical floor. The Veteran submitted a Disability Benefits Questionnaire in October 2016 for his skin condition. A VA physician evaluated the Veteran's skin condition and reported, "The combination of high heat, high humidity and constant friction of starched fatigue pants against [the Veteran's] groin skin while walking guard duty 8 hours per day caused severe inflammation of his groin and scar tissue to develop." The VA physician noted that this condition has continued since service and that it is a "chronic medical condition with no cure." The VA physician also noted that the Veteran is a registered nurse and that this job requires extensive walking, which causes dermatitis of his groin skin and results in further pain. The VA physician's final remarks were that the Veteran's "bilateral groin scars have caused [the Veteran] extreme pain and discomfort since 1965. This is a chronic condition that will remain with him forever." Generally, lay evidence is competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence can be competent and sufficient evidence of a diagnosis if (1) the 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. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a layperson may speak to etiology in some limited circumstances in which a nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. As a nurse, the Veteran is competent to identify his skin condition, which is also supported by later diagnoses from other medical professionals. Moreover, he is able to speak to the etiology of this skin condition based on his continuous observation of his symptoms since they began in service. Lastly, the Veteran's statements regarding etiology are additionally supported by the findings of the October 2016 Disability Benefits Questionnaire. The Board finds this medical opinion highly probative of a positive nexus between the Veteran's current condition and service because it not only contains a clear conclusion with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Based on the foregoing, and resolving any reasonable doubt in the Veteran's favor, the Board finds that service connection for residuals, groin injury is warranted and the claim is granted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Service Connection for Coronary Artery Disease and Diabetes Mellitus, Type II The Veteran contends that he developed coronary artery disease and diabetes mellitus, type 2, as a result of herbicide exposure during service in Okinawa, Japan, between January 1965 and December 1966. The record documents the existence of the Veteran's conditions (coronary artery disease and diabetes mellitus, type 2), first diagnosed many years post-service and followed by non-surgical treatment involving prescribed medications for his diabetes disability, but had surgical treatment involving triple bypass surgery for his heart condition in August 2011. It is neither alleged nor shown that the Veteran's coronary artery disease or diabetes originated in service or that either condition was present within the one-year period immediately following service separation. Rather, the Veteran alleges that these disabilities are the result of his in-service herbicide exposure while he served on active duty in Okinawa, Japan. Two separate August 2016 Disability Benefits Questionnaires also contain positive nexus opinions for coronary artery disease and diabetes mellitus, type 2, as more likely than not due to herbicide exposure. The single question thus presented by the instant appeal is whether the Veteran was in fact exposed to herbicide agents, including Agent Orange, while in service. The Board notes that the Veteran did not serve on active duty in Vietnam or Korea, such that he might be afforded a presumption of in-service herbicide agent exposure. See 38 C.F.R. § 3.307(a)(6)(iii). In support of his in-service exposure, the Veteran points to a similarly situated Veteran who, like himself, served in Okinawa in or about 1962 and later developed prostate cancer and, in that case, the Board granted entitlement to service connection for prostate cancer on the basis of credible evidence sustaining a reasonable probability that the service person was exposed to dioxins while serving in Okinawa and that his prostate cancer was reasonably attributable to his inservice dioxin exposure. See BVA Docket No. 97-05 078 (Jan. 13, 1998). Other past Board decisions are also cited. However, the Board's prior decisions are not precedential. 38 C.F.R. § 20.1303. The decisions of the Board must be based on the particular facts and applicable legal authority specific to the case before it. The Veteran served as an Air Force Security Policeman on Kadena Air Force Base (AFB), specifically Camp Kinser, located in Okinawa, Japan. The Veteran alleges that while stationed in Okinawa, barrels of herbicide agents were sent from Vietnam to Okinawa before being taken to Johnston Island (Atoll). He testified before the undersigned in October 2016 regarding the facts surrounding his exposure to herbicide agents while stationed in Okinawa. The Veteran related that he served as a perimeter guard along the border between Kadena AFB and the Chibana Ammunition Dump, which was part of a unit that was either deployed to Vietnam or supported those operations. He said that he witnessed the perimeter area being sprayed with a chemical that "just killed everything." He said there were many instances where he would have to walk through these recently sprayed areas and that he was also sprayed directly while patrolling the taxiways and runways near the airfields. While the Veteran's specific unit is not listed among those determined explicitly exposed to herbicide agents, the Board determines that the evidence as to whether the Veteran was exposed to herbicide agents is at least in equipoise given the supporting documentation and statements provided by the Veteran. The Veteran has submitted memoranda from the U.S. Air Force regarding use of herbicides and other chemicals for pest control on Okinawa during the 1960s. A variety of other articles relating to the use of Agent Orange, herbicides, and dioxins on Okinawa, were also submitted by the Veteran, including the recovery of Agent Orange barrels that were buried on Okinawa. Another 1971 report by the U.S. Army discusses herbicide stockpiles located at Kadena AFB. Also submitted are various photos of one or more of the areas where the Veteran was stationed in Okinawa that contained barrels of herbicides. Referral of this case was not made because VA determined that the information required to corroborate the Veteran's stressor was insufficient to send to the U.S. Army and Joint Services Records Research Center (JSRRC) and/or insufficient to allow for meaningful research of Air Force or National Archives and Records Administration (NARA) records. Despite efforts made to verify the Veteran's account since he initiated this claim, a decision must be reached based on the evidence developed to date and, on balance, this matter turns on the credibility and probative value of the Veteran's testimony and statements regarding his in-service exposure to herbicide agents. While neither the service department nor DOD confirms the presence of herbicide agents on Okinawa during 1965 and 1966, the Veteran offers a highly credible, consistent account that he was directly exposed thereto during those years while performing his assigned military duties. He has undertaken significant research and provided numerous studies and articles supporting his claim. Because his testimony is highly probative, the record as a whole is at least in relative equipoise as to this particular Veteran's in-service herbicide agent exposure and on that basis, the Board concedes that the claimed exposure occurred and, thus, his coronary artery disease and diabetes mellitus, type 2, are presumed related thereto. Given that such presumption is not adequately rebutted by evidence to the contrary, service connection for coronary artery disease and diabetes mellitus, type 2, due to herbicide agent exposure is granted. This determination is limited to this specific Veteran, based on the facts, testimony, research presented in light of this particular Veteran's circumstances of service. In view of this evidence, the Board shall resolve reasonable doubt in favor of the Veteran and find that he was exposed to herbicide agents. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Therefore, his coronary artery disease and diabetes mellitus, type 2, which each appear to have manifested to a degree of 10 percent or more at some time after service, are presumed connected to such exposure. See 38 C.F.R. §§ 3.307(a)(6)(ii), 3.309(e). As there is no affirmative evidence to the contrary, the Board concludes that service connection is warranted for both coronary artery disease and diabetes mellitus, type 2. See 38 C.F.R. § 3.307(d). Service Connection for a Right Knee Disability The Veteran alleges that he injured his right knee during service and has continued to experience pain since then. Specifically, he claims that he was knocked off the back of a truck by a guard dog while en route to a guard post and fell approximately four feet down before he landed on his hands and right knee. See Board hearing transcript, 17-8. First, the evidence of record demonstrates that the Veteran has current diagnoses for mild right knee arthritis and status post right knee arthroscopy. Service treatment records do not show any treatment for the right knee or other knee abnormalities, to include the Veteran's entrance and separation examinations. However, an in-service injury alone does not mandate that service connection be granted. The in-service injury must be shown to cause his current bilateral knee disability, or to have caused chronic or continuous symptoms of a bilateral knee disability to a degree of 10 percent or more within one year of service to be presumed as incurred in-service. As arthritis is a chronic disease under 38 C.F.R. § 3.309(a), the Board will consider whether the Veteran had chronic symptoms in service or continuity of symptomatology since service have been shown. On the question of continuous symptoms since service, the Board finds that the weight of the evidence demonstrates that the Veteran experienced continuous symptoms of a right knee disability after service separation to warrant presumptive service connection. Id. The Veteran claims that he was pushed out of a truck while stationed in Okinawa and has experienced knee trouble since that time. See Correspondence, received October 26, 2016. Furthermore, the Veteran clarified that while he did not seek medical treatment for his right knee, he was given approximately three weeks of light duty. He said that this injury caused pain and swelling that has continued to bother him throughout service, and that he treated the condition with an ace wrap bandage. He also said that continuous walking "only aggravated the condition." The Veteran reconfirmed these statements in his October 2016 Board hearing testimony before the undersigned. The Board finds that the Veteran is competent to describe symptoms of knee pain. See Layno v. Brown, 6 Vet. App. 465 (1994). The Veteran's ex-wife, who is also a registered nurse, submitted a statement in support of this claim. See Buddy/Lay Statement, received October 26, 2016. She explained that she first met the Veteran in 1967 and that she has been aware of his right knee pain and swelling since then. An October 2016 statement from the Veteran's private treating physician indicates that the Veteran's right knee condition originated in service. The physician stated, "As this [Veteran] never hurt his knee prior to 1966, or since then, I must conclude with a reasonable degree of medical certainty that this is a service connected injury...and is directly and causally related to his continued problems with his knees today." A September 2016 Disability Benefits Questionnaire indicates the Veteran has had chronic knee pain and edema since 1966 due to a fall at Kadena Air Force Base, Okinawa. The VA physician reported that the Veteran's "knee pain and edema are more likely than not due to a fall while in the military, causing a chronic knee condition that was aggravated by extensive walking while on guard duty." The Board has weighed the Veteran's statements, as expressed throughout this decision, regarding continuity of symptomatology and finds that his current recollections and statements made in connection with these claims for benefits to be of great probative value. See Pond, 12 Vet. App. at 341 (although Board must take into consideration the veteran's statements, it may consider whether self-interest may be a factor in making such statements); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). For these reasons, the Board finds that the weight of the evidence is at least in equipoise as to a finding of continuity of symptomatology after service. 38 C.F.R. § 3.303(b). As such, the criteria for presumptive service connection have been met. In this decision, the Board has considered the Veteran's contentions and lay statements as they pertain to a nexus between current complaints and service. Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau, 492 F.3d 1372; see also Buchanan, 451 F.3d at 1331 (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some medical disorders require specialized training for a determination as to diagnosis and causation; therefore, such issues are not susceptible of lay opinions on etiology, and a veteran's statements therein cannot be accepted as competent medical evidence. See Clemons, 23 Vet. App. at 6 (stating that 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"). However, as a registered nurse, the Veteran is competent to identify his right knee disability, which is also supported by later diagnoses from other medical professionals. Moreover, he is able to speak to the etiology of this right knee disability based on his continuous observation of his symptoms since they began in service. Lastly, the Veteran's statements regarding etiology are additionally supported by the findings of the October 2016 Disability Benefits Questionnaire and private physician's assessment. The Board finds these medical opinions highly probative of a positive nexus between the Veteran's current condition and service because they not only contain a clear conclusion with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Throughout the course of this appeal, the Veteran has consistently contended that his right knee disability began during service and continued to worsen since service separation. The Board finds that the Veteran has provided credible statements and testimony as well as lay histories provided to medical personnel that his right knee symptoms have been continuous since service. Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay statements regarding continuity of symptomatology provide a direct link between the active service and the current state of his condition). The Board finds the Veteran's assertions of the onset of a right knee disability during service and his reports of right knee symptomatology since service, in the context of the demonstrated in-service incident, and current diagnosis, are sufficient to place in equipoise the question of whether the current right knee disability was incurred in-service and is etiologically related to the in-service incident. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that, based on continuous post-service symptoms of a right knee disability, presumptive service connection for a right knee disability is warranted under 38 C.F.R. § 3.303(b). 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Bilateral Hearing Loss The Veteran essentially contends that he developed bilateral hearing loss during service that has continued since separation. Specifically, the Veteran states that he experienced acoustic trauma during service due to noise exposure caused by airplane engines without the ability to use of hearing protection. First, the evidence of record demonstrates that the Veteran has a current bilateral hearing loss disability for VA purposes. The threshold for normal hearing is from 0 to 20 decibels. 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 is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. A VA audiology consult note from February 2010 shows pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 25 30 40 55 LEFT 20 25 25 25 30 Speech audiometry revealed speech recognition ability of 84 percent in the right ear and of 88 percent in the left ear. On the authorized private audiological evaluation in July 2010, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 15 20 25 LEFT 10 5 15 20 25 Speech audiometry revealed speech recognition ability of 94 percent in both ears. Accordingly, the Veteran did not present hearing loss for VA purposes under 38 C.F.R. § 3.385 according to these test results. Nonetheless, the record shows that the Veteran did have hearing loss for VA purposes in February 2010. The medical evidence of record does not demonstrate that the Veteran sustained any in-service hearing loss. The Veteran's service treatment records show that he did not have any complaints, treatment, or diagnosis for hearing loss. His hearing examination at separation was essentially "normal." Service treatment records do not reflect any complaint, treatment, or diagnosis of a hearing loss disability, or otherwise reflect a reported history or findings of an auditory injury. Although the Veteran was not specifically diagnosed with a hearing loss disability of either ear in active service, such is not required. See 38 C.F.R. § 3.303(d) (providing service connection may be granted for any disease diagnosed after service when the evidence establishes in-service incurrence); Hensley, 5 Vet. App. at 159 (holding that service connection is not precluded for hearing loss which first met VA's definition of disability at 38 C.F.R. § 3.385 after service). The lay evidence of record demonstrates acoustic trauma in service and the Veteran has also reported noticing that his hearing diminished during service and continued to worsen since service separation. See October 2016 Board hearing transcript. The Veteran testified before the undersigned that he was exposed to acoustic trauma from in-service noise exposure due to his job as a security police officer patrolling near the flight lines without the use of hearing protection. See id. The Veteran explained that he first noticed hearing loss in the month following discharge from service. He stated that he had just been married within that first month following discharge and that his wife brought it to his attention that he had to "play the TV very loud so that [he] could hear it." He also stated that his hearing loss has continued to deteriorate since he was discharged from service. The Veteran is competent to report noise exposure in service. See Bennett v. Brown, 10 Vet. App. 178 (1997) (the Board may rely upon lay testimony as to observable facts). Moreover, the Veteran's service records confirm that his military occupation was "Security Police." A separation qualification record noted that the Veteran had military training as "Air Police." The Board finds that the evidence is at least in equipoise on the question of whether symptoms of bilateral hearing loss have been continuous since service. There can be no doubt that further medical inquiry could be undertaken with a view towards development of the claim. Specifically, the audiological testing results show hearing loss for VA purposes in February 2010, but does not contain a medical opinion, while the July 2010 audiological testing results do not show hearing loss. More recent VA treatment records note an active diagnosis for bilateral sensorineural hearing loss and prescribed hearing aids. However, the Board finds that the evidence is at least in equipoise on the question of whether symptoms of bilateral hearing loss have been continuous since service. Although the Veteran was not specifically diagnosed with a hearing loss disability of either ear in active service, such is not required. See 38 C.F.R. § 3.303(d) (providing service connection may be granted for any disease diagnosed after service when the evidence establishes in-service incurrence); Hensley , 5 Vet. App. at 159 (holding that service connection is not precluded for hearing loss which first met VA's definition of disability at 38 C.F.R. § 3.385 after service). The evidence of record demonstrates acoustic trauma in service and the Veteran has reported noticing that his hearing diminished during service and continued to worsen since service separation. In this case, the Veteran is competent to report symptoms of hearing loss because this requires only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Throughout the course of this appeal, the Veteran has consistently contended that his hearing loss began during service and continued to worsen since service separation. The Board finds that the Veteran has provided credible statements and testimony as well as lay histories provided to medical personnel that his hearing loss symptoms have been continuous since service. Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay statements regarding continuity of symptomatology provide a direct link between the active service and the current state of his condition). Audiometric testing post-service demonstrate that the Veteran's hearing acuity continued to decline after service separation. The Board finds the Veteran's assertions of the onset of bilateral hearing loss during service and his reports of bilateral hearing loss symptomatology since service, in the context of the demonstrated in-service acoustic trauma, and current diagnosis, are sufficient to place in equipoise the question of whether the current bilateral hearing loss was incurred in service and is etiologically related to the noise exposure in service. For these reasons, and resolving reasonable doubt in the Veteran's favor, the Board finds that, based on continuous post-service symptoms of bilateral hearing loss, presumptive service connection for bilateral hearing loss is warranted under 38 C.F.R. § 3.303(b). 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Duties to Notify and Assist VA has duties to notify and assist veterans in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2016). The Board is granting, in full, the benefits sought on appeal and thus VA has no further duty to notify or assist. ORDER New and material evidence has been submitted to reopen the claim of service connection for residuals, groin injury. Service connection is granted for residuals, groin injury. Service connection is granted for coronary artery disease, to include as due to herbicide exposure. Service connection is granted for diabetes mellitus, type 2, to include as due to herbicide exposure. Service connection is granted for a right knee disability. Service connection is granted for bilateral hearing loss. ______________________________________________ H. SEESEL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs