Citation Nr: 1800403 Decision Date: 01/04/18 Archive Date: 01/19/18 DOCKET NO. 06-08 007 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Houston, Texas THE ISSUES 1. Entitlement to a disability rating in excess of 30 percent for recurrent furunculosis, previously rated as hydradenitis and as status post-operative pilonidal cystectomy on groin area. 2. Entitlement to service connection for a right shoulder disability. 3. Entitlement to service connection for tinnitus. 4. Entitlement to service connection for a bilateral hearing loss disability. REPRESENTATION Veteran represented by: Texas Veterans Commission WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Delhauer, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1974 to June 1977. The Veteran also served in the National Guard from April 1978 to April 1996. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2005 rating decision by a Department of Veterans Affairs Regional Office (RO). In March 2010, the Veteran testified at a videoconference hearing before a Veterans Law Judge (VLJ). A transcript of the hearing is associated with the evidentiary record. In June 2010, these matters were remanded by the Board for further development. In a December 2012 rating decision, the Agency of Original Jurisdiction (AOJ) granted entitlement to service connection for posttraumatic stress disorder (PTSD), and service connection for status post lesion removal scars on the Veteran's anterior thigh, right leg; anterior thigh, left leg; anterior trunk, left axilla; anterior trunk, base of penis; and posterior trunk, left buttock. As these decisions represent full grants of the benefits sought, the issues of service connection for PTSD and for chronic cysts on the left leg, stomach, right hip, left hip, and penis are no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). In July 2017, the Board notified the Veteran that the VLJ who conducted the March 2010 hearing was not available to decide the appeal, and he had the right to another Board hearing. This notice informed the Veteran that if he did not respond within 30 days from the date of the letter, the Board would assume he did not want another hearing and would proceed with a decision in this case. To date, the Board has not received a response from the Veteran and will assume he does not wish to participate in another hearing. In a February 2013 rating decision, the AOJ denied the Veteran's claim of entitlement to service connection for loss of sphincter control. In February 2014, VA received the Veteran's notice of disagreement with the February 2013 rating decision. In an August 2014 statement of the case, the AOJ denied service connection for loss of sphincter control as secondary to the service-connected disability of scar, superior to anus, status post pilonidal cystectomy. A substantive appeal was not received in response to the August 2014 statement of the case. Accordingly, the Board finds the Veteran did not perfect an appeal as to the issue of service connection for loss of sphincter control and thus, it is not currently before the Board. The issue of service connection for a bilateral hearing loss disability is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. Throughout the appeal period, the Veteran's recurrent furunculosis was manifested by skin lesions affecting at most 25 percent of the entire body and less than 20 percent of exposed areas. 2. From May 15, 2007 to September 9, 2015, there is an approximate balance of positive and negative evidence as to whether the Veteran's recurrent furunculosis required constant or near-constant use of oral antibiotics. 3. Prior to May 15, 2007, and from September 9, 2015, the Veteran's recurrent furunculosis required what more nearly approximates treatment with oral antibiotics for a total duration of six weeks or more, but not constantly. 4. There is an approximate balance of positive and negative evidence as to whether the Veteran's recurrent furunculosis has been manifested throughout the appeal period by a chronic peri-rectal pain syndrome caused by the status post-operative pilonidal cystectomy. 5. The preponderance of competent and credible evidence weighs against finding that the Veteran's current right shoulder disability manifested within a year of his separation from active duty service, or was incurred in or is otherwise related to his military service. 6. There is an approximate balance of positive and negative evidence as to whether the Veteran's current tinnitus is related to his military service. CONCLUSIONS OF LAW 1. Prior to May 15, 2007, the criteria for a disability rating in excess of 30 percent for recurrent furunculosis were not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7806 (2017). 2. Resolving reasonable doubt in favor of the Veteran, from May 15, 2007 to September 9, 2015, the criteria for a disability rating of 60 percent for recurrent furunculosis were met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7806 (2017). 3. From September 9, 2015, the criteria for a disability rating in excess of 30 percent for recurrent furunculosis have not been met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.7, 4.118, Diagnostic Code 7806 (2017). 4. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for a chronic peri-rectal pain syndrome as secondary to the service-connected recurrent furunculosis, previously rated as status post-operative pilonidal cystectomy, have been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 5. The criteria for service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307 (2017). 6. Resolving reasonable doubt in favor of the Veteran, tinnitus was incurred in military service. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate the claims. Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board...to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Increased Rating Rating Principles A disability rating is determined by the application of VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings." Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). There is no Diagnostic Code that specifically addresses recurrent furunculosis, previously rated as hydradenitis and as status post-operative pilonidal cystectomy on groin area; therefore, the Veteran's skin disorder has been evaluated to an analogous skin disability under Diagnostic Code 7806. Under this diagnostic code, in relevant part, a 30 percent disability rating is warranted for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or, systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating is warranted for more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or, constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. 38 C.F.R. § 4.118. Analysis The Veteran contends that his service-connected skin disability has worsened to the degree that it warrants a higher disability rating. See, e.g., February 2006 Veteran statement; May 2004 Veteran statement. The Veteran contends he suffers from chronic, painful cysts on his groin area and buttocks, as well as residual pain from his pilonidal cyst surgery, all of which affects his ability to perform at work. See, e.g., March 2010 hearing testimony; May 2006 VA IMC progress note (summary of medical problems for disability submission); November 2005 notice of disagreement. First, in the December 2012 rating decision the AOJ granted entitlement to a separate 10 percent disability rating for scar, superior to anus, status post pilonidal cystectomy, based upon the finding the scar is painful. This award was effective May 26, 2004, the date of the Veteran's claim for an increased disability rating for his service-connected recurrent furunculosis, previously rated as status post-operative pilonidal cystectomy. To date the Veteran has not expressed disagreement with that decision, and as such the separate 10 percent disability rating throughout the appeal period for the Veteran's painful pilonidal cystectomy scar is not currently before the Board. Following careful review of all the evidence of record, to include the Veteran's VA treatment records, VA examination reports, and the competent and credible lay statements and testimony of record, the Board finds that throughout the appeal period the Veteran's service-connected skin disability affected at most 25 percent of the entire body and less than 20 percent of the exposed areas. Throughout the appeal period, the Veteran's VA treatment records include intermittent complaints of lesions, at times referred to as boils, cysts, or carbuncles, related to his service-connected skin condition. The records indicate the Veteran would experience one-to-two lesions at a time on his upper thighs, groin, or buttocks, some of which had to be excised, and one or two of which were slow to heal. See, e.g., September 2012 VA IMC progress note; April 2008 VA dermatology note; May 2007 VA dermatology note; January 8, 2007 VA emergency department E&M note; January 2007 VA IMC progress note and addendum; January 3, 2007 VA emergency department E&M note; July 2006 VA IMC progress note; May 2006 VA IMC progress notes; April 2006 VA urology note; April 2006 VA general surgery post-operative note; March 2006 VA general surgery note; March 2006 VA general surgery consultation; March 2006 VA IMC progress note; October 7, 2005 VA IMC progress note; October 4, 2005 VA IMC progress note; June 2005 addendum to UCC 10-10M note; June 2005 VA primary care nursing note; April 2005 VA IMC progress note. However, VA treatment records also indicate the Veteran often had no active lesions. See, e.g., January 2016 VA physician emergency department note; March 2010 hearing testimony; August 2009 VA IMC progress note; October 2008 VA dermatology consultation; September 2008 VA IMC progress note; November 2007 VA dermatology note; February 2007 Va IMC progress note; August 2005 VA IMC progress note; July 2005 VA IMC progress note; May 2005 VA IMC progress note. In January 2008, the Veteran complained of itching in the groin. However, the Veteran's treating VA dermatologist attributed this rash to tinea cruris, and not related to the Veteran's service-connected skin condition. See June 2008 VA dermatology note; April 2008 VA dermatology note. During the November 2004 VA examination, the VA examiner noted the Veteran had one lesion in his right lower quadrant drained on several occasions in the previous year, but the lesion was not present upon examination. Further, the Veteran's other lesions were noted to be quiescent, and had been since the time they were operated on prior to the appeal period, and no symptomatic lesions were present. The November 2004 VA examiner stated no body area was currently affected, to include any exposed areas. The Veteran was afforded another VA examination in March 2007. At that time, the VA examiner reported the Veteran's skin condition affected 25 percent of his total body area, and none of the exposed areas. At the September 2012 VA skin diseases examination, the Veteran reported he had not had a problem with folliculitis for over a year. The VA examiner stated the Veteran's service-connected skin condition affected 5 to less than 20 percent of his total body area, and 5 to less than 20 percent of exposed areas. During the September 2015 LHI skin diseases examination, the examiner reported the Veteran's furunculosis affected 5 to less than 20 percent of his total body area, and none of the exposed areas. Following the April 2017 VA skin diseases examination, the VA examiner reported there were no current active or visible cysts at that time, so zero percent of the total body was affected. Accordingly, because throughout the appeal period the Veteran's service-connected skin condition affected at most 25 percent of his total body and less than 20 percent of the exposed areas, a disability rating in excess of 30 percent under Diagnostic Code 7806 based upon the percentage of areas affected is not warranted at any time during the appeal period. See 38 C.F.R. § 4.118. However, the Board finds the evidence of record indicates the Veteran did require treatment with oral antibiotics during the appeal period. There is nothing in the rating criteria to suggest that systemic antibiotic therapy is insufficient to warrant a rating under Diagnostic Code 7806. The Federal Circuit Court has held that systemic therapy means "treatment pertaining to or affecting the body as a whole," whereas topical therapy means treatment pertaining to a particular surface area, as a topical anti-infective applied to a certain area of the skin and affecting only the area to which it is applied, and that nothing in Diagnostic Code 7806 displaces the accepted understandings of systemic therapy and topical therapy to permit a topical therapy that affects "only the area to which it is applied" to count as a systemic therapy under that code. The use of a topical corticosteroid could be considered either systemic therapy or topical therapy based on the factual circumstances of each case. The use of topical corticosteroids does not automatically mean systemic therapy because Diagnostic Code 7806 distinguishes between systemic and topical therapy. Johnson v. Shulkin, 862 F.3d 1351 (Fed. Cir. 2017). Prior to May 15, 2007, the Veteran's VA treatment records indicate his service-connected skin lesions were treated with combinations of topical creams and short courses of oral antibiotics until the lesions cleared. See, e.g., March 2007 VA examination report; January 8, 2007 VA emergency department E&M note; January 3, 2007 VA emergency department E&M note; July 2006 VA IMC progress note; May 2006 VA IMC progress notes (clindamycin at home to use if folliculitis flares); March 2006 VA general surgery note; March 2006 VA general surgery consultation; October 2005 VA IMC progress note; July 2005 VA IMC progress note; June 2005 addendum to UCC 10-10M note; April 2005 VA IMC progress note. The Board finds the repeated, short-term prescriptions for oral antibiotics until the lesions cleared are consistent with systemic therapy required for a total duration of six weeks or more, but not constantly, during a 12 month period, commensurate with a 30 percent disability rating. 38 C.F.R. § 4.118, Diagnostic Code 7806; Johnson, 862 F.3d 1351. During the May 15, 2007 VA dermatology visit, the physician noted the Veteran's history of getting one-to-two lesions every one-to-two months, and that he had never taken any medications to control the condition. The physician prescribed a topical medication for washes, and Doxycline, an oral antibiotic. The Veteran's VA treatment records indicate the Veteran continued to use the oral antibiotics to treat his service-connected skin condition until at least October 2008. At that time, his treating VA dermatologist stated he could stop the Doxycycline because he had not had a problem with his recurrent folliculitis in a long time, but he was instructed to restart the medication if he started to get more lesions. An April 2009 VA medication management note indicates the Veteran was not taking this medication at that time, but requested his medication not be discontinued in case he needed to restart it again for his skin condition. See also August 2009 VA IMC progress note (currently off all topical and oral medications for his chronic abscesses). During the September 2012 VA skin diseases examination, the VA examiner stated the Veteran's furunculosis had been doing well, controlled on Doxycycline. The examiner reported the Veteran's recurrent skin infections were controlled by constant or near-constant use of an oral medication, antibiotic therapy. Later in September 2012, the Veteran was prescribed a different oral antibiotic for a cyst. See September 2012 VA IMC progress note. Following the September 9, 2015 LHI skin diseases examination, the examiner reported the Veteran had not treated his service-connected skin condition with oral or topical medications in the previous 12 months. The Board finds that a 60 percent disability rating is warranted due to the Veteran's constant use of oral antibiotic therapy beginning May 15, 2007, the date the medication was prescribed by his VA dermatologist. The Board finds there is an approximate balance of positive and negative evidence as to whether the Veteran's service-connected skin condition required constant or near-constant systemic therapy in the form of oral antibiotics until September 9, 2015, the first date it was factually ascertainable the Veteran was no longer prescribed oral antibiotics on more than an intermittent basis. Accordingly, the Board affords the Veteran the benefit of reasonable doubt, and finds the criteria for a 60 percent disability rating, the schedular maximum, have been met from May 15, 2007 to September 9, 2015. 38 C.F.R. § 4.118, Diagnostic Code 7806. As of the September 2015 LHI examination, the medical evidence of record does not indicate the Veteran was prescribed or used any systemic therapy to treat his service-connected skin disability. See April 2017 VA examination report. Accordingly, the Board finds the criteria for a disability rating in excess of 30 percent from September 9, 2015 have not been met. 38 C.F.R. § 4.118, Diagnostic Code 7806. In summary, the Board finds no provision upon which to assign the Veteran a disability rating in excess of 30 percent for recurrent furunculosis prior to May 15, 2007. The Board finds the criteria for a 60 percent disability have been met from May 15, 2007 to September 9, 2015. However, the Board finds no provision upon which to assign the Veteran a disability rating in excess of 30 percent from September 9, 2015. 38 C.F.R. § 4.118, Diagnostic Code 7806. However, the Board does find that the totality of the evidence of record indicates that throughout the appeal period, the Veteran has complained of pain in the region of his abdomen, groin, and/or buttocks which he contends is related to his service-connected skin disability, and which is separate from the pain associated with the residual scar from his pilonidal cystectomy. The Veteran contends this pain causes him difficulties at work including lost time, and has limited his activities including exercising due to painful movement. See, e.g., April 2017 VA skin diseases examination report; August 2016 VA psychiatry outpatient follow-up note; June 2014 notice of disagreement; September 2012 VA examination report; July 2012 L.A.C. statement; March 2010 videoconference hearing testimony; September 2009 Veteran statement; March 2009 VA orthopedic surgery attending note; September 2008 VA IMC progress note; July 2007 representative statement; June 2007 VA IMC progress note; May 2006 VA IMC progress notes; May 2006 L.M.L. statement; July 2005 VA IMC progress note; July 2005 VA psychiatry evaluation; February 2005 former girlfriend statement; February 2004 VA IMC progress note. In February 2013, the Veteran was afforded a VA rectum and anus examination. The VA examiner noted the Veteran's 1977 surgery for the pilonidal cyst, and the Veteran's report that since that surgery bending, squatting, and picking up heavy items cause pain and pain flares. The Veteran reported that when picking up a 20 pound sandbag he will experience throbbing in the abdomen and in between the cheeks, with pain and swelling located around the scar. The examiner also noted the Veteran's reports of experiencing pain or discomfort when sitting on hard objects. The Veteran also reported that his work is inhibited some by his pain in the rectal area with heavy lifting, bending, and squatting. The February 2013 VA examiner noted that upon examination, sensation to the buttocks was altered compared to the thigh. The Veteran described it as "squishy," which the examiner stated indicated not completely normal sensation but not quite numbness. The February 2013 VA examiner indicated the Veteran's abnormal sensations (chronic perirectal pain), are a residual from the excision of the Veteran's peri-rectal abscess, the pilonidal cystectomy. Accordingly, the Board affords the Veteran the benefit of reasonable doubt, and finds the totality of the medical evidence indicates the Veteran's service-connected skin disorder was manifested by a chronic perirectal pain syndrome caused by the post-operative pilonidal cystectomy throughout the appeal period. Accordingly, the Board finds a grant of service connection for chronic perirectal pain syndrome is warranted. See 38 C.F.R. § 3.310. As shown above, and as required by Schafrath, 1 Vet. App. at 594, the Board has considered all potentially applicable provisions of 38 C.F.R. Parts 3 and 4, whether or not they have been raised by the Veteran. In this case, the Board finds no provision upon which to assign the Veteran a disability rating in excess of 30 percent for recurrent furunculosis prior to May 15, 2007. The Board finds the criteria for a 60 percent disability have been met from May 15, 2007 to September 9, 2015. However, the Board finds no provision upon which to assign the Veteran a disability rating in excess of 30 percent from September 9, 2015. Further, the Board finds that entitlement to service connection for chronic peri-rectal pain syndrome as secondary to the service-connected recurrent furunculosis is warranted, as it was caused by, and is a manifestation of, the post-operative pilonidal cystectomy. Total Disability Rating Based on Individual Unemployability (TDIU) Finally, in the case of Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a claim for a TDIU due to service-connected disabilities is part and parcel of an increased rating claim when such claim is raised by the record. In the October 2005 rating decision, the RO denied the Veteran's claim of entitlement to a TDIU. The Veteran did not indicate disagreement with that decision in his November 2005 notice of disagreement. Further, the Board's review of the evidentiary record indicates that while the Veteran has reported his recurrent furunculosis, to include the chronic peri-rectal pain syndrome, affects him at work, as discussed above, the Board finds the evidence of record does not indicate the Veteran has claimed he is unable to obtain and maintain a substantially gainful occupation due to this condition. Further, the evidence of record indicates the Veteran continues to work full time. See, e.g., April 2017 VA skin diseases examination report. Accordingly, the Board finds the issue of entitlement to a TDIU has not been raised by the record. Service Connection Legal Criteria A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C. §§ 1110, 1131. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Id. Service connection may be granted on a presumptive basis for certain chronic diseases, including arthritis and tinnitus, if they are shown to be manifest to a degree of 10 percent or more within one year following a veteran's separation from active military service. 38 C.F.R. §§ 3.307, 3.309; Fountain v. McDonald, 27 Vet. App. 258 (2015). The United States Court of Appeals for the Federal Circuit, however, has clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). Analysis The Board notes the Veteran's service treatment records and service personnel records from his National Guard service are missing, and VA has otherwise been unable to obtain the Veteran's records from this period of service. See June 2012 notification letter to the Veteran; June 2012 Formal Finding of Unavailability. The Court has held that in cases where records once in the hands of the Government are lost, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). The Board's analysis of the claims has been undertaken with this heightened duty in mind. Right Shoulder Disability The first element of Shedden is met, as the medical evidence of record contains diagnoses of a right shoulder rotator cuff tear, tendonitis, and degenerative joint disease (arthritis) with a large distal clavicle exostosis. See May 2005 VA orthopedic surgery outpatient procedure report; July 2004 VA orthopedic note; May 2004 VA IMC progress note; February 2004 VA IMC progress note. The Veteran's service treatment records from his period of active duty service do not include any complaints, diagnoses, or treatment related to his right shoulder. The Veteran contends that during his National Guard service around 1979 or 1980, he injured his right shoulder in an accident in an armored personnel carrier (APC). The Veteran contends another soldier was driving but that individual did not know how to drive the APC, was speeding, and veered to the right and hit a pole. The Veteran testified before the Board that he did not seek medical treatment at that time, but that the accident was documented. See March 2010 hearing testimony; January 2007 representative statement. As the Veteran contends his right shoulder disability was incurred during his National Guard service, in order to establish service connection he would need to establish that he was disabled from a disease or injury incurred or aggravated in the line of duty during that service, such as while on active duty for training (ACDUTRA). 38 C.F.R. §§ 3.1(a), (d), 3.6(c); Harris v. West, 13 Vet. App. 509, 511 (2000); Paulson v. Brown, 7 Vet. App. 466, 470 (1995). In this case, because the Veteran's service treatment records and full service personnel records from his National Guard service are unavailable, the Board cannot verify that the Veteran's right shoulder was injured in an APC accident during a period of ACDUTRA. However, even if the Board was to assume the Veteran was involved in an APC accident during a period of ACDUTRA, the Board finds the preponderance of the competent and credible evidence of record is against finding that the Veteran's current right shoulder disability is related to that accident or his military service. The Veteran contends that he has experienced pain in his right shoulder since the APC accident, but that he just dealt with the pain. However, he testified before the Board that after he re-injured the shoulder at work, the pain progressed to the point that he sought medical attention. See March 2010 hearing testimony; see also September 2006 VA psychology report; January 2006 VA IMC progress note. The medical evidence of record does not include any complaints of right shoulder symptoms until 2001, at which time the Veteran complained of right shoulder pain and limitation of motion. However, x-rays taken in April 2001 were negative. See April 2001 VA x-ray report; see also July 2001 former girlfriend statement (the Veteran complained of numbness and tingling in his arms and shoulders at night). The Veteran's VA treatment records indicate that in the spring of 2003 the Veteran injured his right arm at work while working on a steel bridge. At first, the Veteran complained of an injury to his right elbow. See May 2003 VA IMC progress note; March 2003 VA UCC 10-10M note. In January 2004, the Veteran reported that this work injury also "jarred" his right shoulder, and he reported two other accidents involving his right shoulder, including one about one year prior. At that time, right shoulder pain was assessed, and the VA provider stated the Veteran most likely had a component of osteoarthritis from multiple injuries as well as possible tendonitis, and possible impingement. See January 2004 VA IMC progress note. In January 2004, the Veteran complained of right shoulder pain and aching for about six-to-seven months. See January 2004 VA UCC 10-10M note. In April 2005, a VA orthopedic surgeon noted the Veteran's report that he had injured his right shoulder in the military, and that the shoulder was re-injured in 2002 [sic]. The surgeon noted the Veteran worked in construction and performed overhead work. See April 2005 VA surgery risk assessment and history and physical note. The Veteran's VA treatment records indicate that his treating VA practitioners have attributed the Veteran's current right shoulder disability, to include the diagnoses preceding his 2005 right shoulder surgery, to his work injury in 2003. See, e.g., October 2012 VA IMC progress note (initial minor insults to the shoulders in the 1970s, and minor aggravations to his shoulders in the 1990s); March 2009 VA orthopedic surgery note. As the medical evidence of record indicates no right shoulder disability was diagnosed as of 2001, and a right shoulder disability was not diagnosed until 2003 following an injury at work, the Board finds the preponderance of the competent and credible medical evidence of record is against finding that the Veteran's current right shoulder arthritis manifested within one year of his separation from active duty service, or that the Veteran's current right shoulder disability is related to his active duty service or an injury suffered during an APC accident during his National Guard service. 38 C.F.R. §§ 3.303, 3.307. The Board has considered the lay evidence offered by the Veteran. This includes his contentions that his current right shoulder disability is related to the APC accident, and that he has experienced right shoulder symptoms, to include pain, ever since that accident. In general, lay witnesses are competent to testify as to their observations as well as opine on questions of diagnosis and etiology in some circumstances. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (lay witnesses are competent to testify as to their observations, but this testimony must be weighed against the other evidence of record); Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). However, the question of whether the Veteran's current right shoulder disability is related to his military service cannot be determined by mere observation alone. The Board finds that determining whether the Veteran's military service, to include any APC accident and injury to the right shoulder, caused his current right shoulder disability is not within the realm of knowledge of a non-expert, given the length of time between the Veteran's active duty service, the alleged APC accident in about 1980, and the first medical records of right shoulder complaints in 2001; the reports of record of multiple injuries to the Veteran's right shoulder over the years, including the work injury in 2003; and the first right shoulder diagnoses of record in January 2004. As the evidence does not show that the Veteran has expertise in medical matters, the Board concludes that his nexus opinion in this regard is not competent evidence and therefore is not probative of whether his current right shoulder disability was caused by his military service. Here, there is no competent evidence or opinion suggesting that there exists a medical nexus between the current right shoulder disability and the Veteran's military service. Accordingly, the Board finds the preponderance of competent and credible evidence weighs against finding that the Veteran's current right shoulder disability was caused by his military service, and service connection cannot be established. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For the foregoing reasons, the Board must conclude that the preponderance of the evidence is against the claim of entitlement to service connection for a right shoulder disability. The benefit of the doubt doctrine is therefore not applicable, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). Tinnitus The first element of Shedden is met, as recurrent tinnitus has been diagnosed. See February 2013 VA examination report; May 2010 Lackland Air Force Base (AFB) audiology treatment note; April 2008 VA audiology notes. The Veteran's former representative contended the Veteran experienced routine noise exposure during service from gunfire, munitions, and power equipment. See July 2007 representative statement. The Veteran contends that during active duty his Military Occupational Specialty involved blowing demolition and mines, and building bridges, which involved exposure to acoustic trauma. The Veteran also contends that during his National Guard service his duties as a boat operator in an engineering unit that built bridges also exposed him to noise. See September 2009 Veteran statement. The Veteran testified before the Board that he experienced acoustic trauma because as a service engineer, about 90 percent of his time in the National Guard was spent conducting war games, and he was exposed to noise that would shake the building and make the ground shake from C4 explosives, M50 and M60 machine guns, and claymore mines. The Veteran testified the noise exposure during his National Guard service was nearly constant. The evidence of record indicates that during his active duty service, the Veteran served as a carpenter. See DD Form 214. During his National Guard service, the Veteran served as an indirect fire infantryman and a combat engineer. See NGB Form 22. Accordingly, the Board will afford the Veteran the benefit of reasonable doubt, and finds the Veteran was exposed to noise during his military service. As such, the second element of Shedden is met. The Veteran contends his current tinnitus is related to his noise exposure during service. See, e.g., March 2010 hearing testimony; September 2009 Veteran statement; October 2004 informal claim. The Veteran contends that his tinnitus began during his National Guard service. See March 2010 hearing testimony; September 2009 Veteran statement. The Veteran was afforded a VA audiology examination in February 2013. The Veteran reported his tinnitus began in the late 1980s, about 1987. The examiner stated the Veteran connected the onset of the tinnitus to explosions while on active duty and in the National Guard. The February 2013 VA examiner opined it is less likely than not the Veteran's tinnitus was caused by or a result of his military noise exposure because there was no significant threshold shift in his hearing when comparing his active duty enlistment and separation physical examination reports, so there were no objective factors seen for which the etiology of the tinnitus could be attributed. The Veteran is competent to discuss observed physical symptoms, such as ringing in the ears. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Charles v. Principi, 16 Vet. App. 370, 374-75 (2002) ("ringing in the ears is capable of lay observation"). Tinnitus, moreover, is a disorder uniquely ascertainable by the senses. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). That is, tinnitus is defined as a ringing in the ears, a finding that can be determined by the Veteran's reporting of the condition. Although the February 2013 VA examiner's nexus opinion was negative, the Board notes it was based on a finding there were no objective factors noted during the Veteran's active duty service related to the Veteran's claimed hearing loss. However, the Veteran contends he was exposed to noise throughout his active duty and National Guard service, and that he first experienced tinnitus in the 1980s during his National Guard service. Further, the Board notes the Veteran has consistently reported that he first experienced tinnitus in service, and that he has experienced tinnitus since service. As discussed above, the Veteran is competent to testify as to his observed symptoms. The Board finds that the Veteran's assertions are credible. The Board has no reason to doubt the Veteran's assertions that he incurred acoustic trauma during service which caused tinnitus, and which he has experienced since service. As the evidence for and the evidence against the Veteran's claim is in relative equipoise, the Board affords the Veteran the benefit of the doubt, and finds there is medical evidence of record establishing a link between the Veteran's noise exposure in service and his tinnitus. Accordingly, the Board finds that a grant of service connection is warranted for tinnitus. ORDER Entitlement to a disability rating in excess of 30 percent for recurrent furunculosis prior to May 15, 2007 is denied. Entitlement to a disability rating of 60 percent for recurrent furunculosis from May 15, 2007 to September 9, 2015 is granted. Entitlement to a disability rating in excess of 30 percent for recurrent furunculosis from September 9, 2015 is denied. Entitlement to service connection for chronic peri-rectal pain syndrome as secondary to recurrent furunculosis, previously rated as status post-operative pilonidal cystectomy, is granted. Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for tinnitus is granted. REMAND Regarding the Veteran's claim of service connection for a bilateral hearing loss disability, the medical evidence of record indicates the Veteran has a current hearing loss disability in his right ear pursuant to 38 C.F.R. § 3.385. See, e.g., February 2013 VA examination report. As discussed above, the Board finds the Veteran was exposed to noise during both his active duty and National Guard service. Following the February 2013 VA audiology examination, the VA examiner opined the Veteran's current right ear hearing loss disability was less likely as not caused by or a result of an event in military service because the Veteran's hearing was normal upon his active duty enlistment and separation physical examinations, and there was no significant threshold shift when comparing the two evaluations. However, the February 2013 VA examiner did not address the Veteran's noise exposure throughout his National Guard service, or the first diagnosis of record of right ear hearing loss for VA purposes upon a January 1999 audiogram performed at Lackland AFB, which was only about two and a half years following the Veteran's separation from the National Guard. On remand, the AOJ should obtain any updated VA treatment records, and then afford the Veteran a new VA examination to determine the nature and etiology of any current bilateral hearing loss disability. Accordingly, the case is REMANDED for the following action: 1. The AOJ should obtain all outstanding VA treatment records, to include from March 2017 to the present, to include any audiogram reports. All obtained records should be associated with the evidentiary record. 2. After the above development has been completed, and after any records obtained have been associated with the evidentiary record, the Veteran should be afforded a VA examination with an appropriate examiner to determine the nature and etiology of any bilateral hearing loss disability. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. The examiner should elicit a full history from the Veteran. All necessary tests and studies should be accomplished, and all clinical findings should be reported in detail. After the record review, and a thorough examination and interview of the Veteran, the VA examiner should offer his/her opinion with supporting rationale as to the following inquiries: a) Is it at least as likely as not (i.e. probability of 50 percent or greater) that any current sensorineural hearing loss disability manifested within a year of the Veteran's separation from active duty service? b) Is it at least as likely as not (i.e. probability of 50 percent or greater) that any current hearing loss disability was either incurred in, or is otherwise related to, the Veteran's military service, to include his National Guard service? The examiner should specifically address the Veteran's contention that his current bilateral hearing loss disability is related to his noise exposure during both his active duty and National Guard service, and that he first noticed his hearing loss during his National Guard service. The examiner should specifically address the January 1999 audiogram from Lackland AFB showing hearing loss for VA purposes in the right ear, about two and a half years after the Veteran's separation from National Guard service. The complete rationale for all opinions should be set forth. 3. After the above development has been completed, readjudicate the claim. If the benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case, and return the case to the Board. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim 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. §§ 5109B, 7112 (2012). ______________________________________________ S. HENEKS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs