Citation Nr: 1800913 Decision Date: 01/08/18 Archive Date: 01/19/18 DOCKET NO. 13-04 880 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for bilateral hearing loss disability. 2. Entitlement to service connection for tinnitus. 3. Entitlement to service connection for headaches, dizziness, and numbness, to include as residuals of a traumatic brain injury (TBI). 4. Entitlement to service connection for a right ankle disorder. 5. Entitlement to service connection for a low back disorder. 6. Entitlement to service connection for an upper back (neck) disorder. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD P.S. Rubin, Counsel INTRODUCTION The Veteran served on active duty in the United States Army from March 1984 to February 1988. He also previously served in the Georgia Army National Guard in 1982 and 1983, with an initial period of active duty for training (ACDUTRA) from July 1982 to October 1982. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In June 2016, the Veteran and his spouse presented testimony at a Board videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the Veteran's claims file. In November 2016, the Board remanded the appeal for further development. The case has since been returned to the Board for appellate review. In the same November 2016 Board decision, the Board awarded the Veteran service connection for a left foot disorder. Thus, this issue is no longer on appeal before the Board. FINDINGS OF FACT 1. The Veteran has current tinnitus and bilateral hearing loss disability for VA compensation purposes. 2. The Veteran's tinnitus and bilateral hearing loss disability are the result of hazardous noise exposure from the firing of guns, due to his in-service duties as an infantryman and a rifleman while serving from 1984 to 1988 with the U.S. Army. 3. The Veteran has a headache disorder that began during his active military service as a residual of his confirmed in-service TBI. 4. The Veteran's current right ankle disorder did not manifest in service and is not related to any event or incident of his active service from 1984 to 1988, including his documented in-service right ankle treatment. 5. The Veteran's current low back disorder did not manifest in service and is not related to any event or incident of his active service from 1984 to 1988, including his documented in-service trailer hitch injury and resulting treatment for low back pain. 6. The Veteran's current neck / upper back disorder did not manifest in service and is not related to any event or incident of his active service from 1984 to 1988, including his documented in-service trailer hitch injury. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in his favor, the criteria for service connection for bilateral hearing loss disability are met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 1154(a), 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.385 (2017). 2. Resolving all reasonable doubt in his favor, the criteria for service connection for tinnitus are met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 1154(a), 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 3. Resolving all reasonable doubt in his favor, the Veteran has a headache disorder that was incurred in active military service. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310(a), (d). 4. A right ankle disorder was not incurred in or aggravated during a period of active service. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 5. A low back disorder was not incurred in or aggravated during a period of active service. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). 6. A neck / upper back disorder was not incurred in or aggravated during a period of active service. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (2012); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). In the decision below, the Board has granted the Veteran's claims for service connection for bilateral hearing loss, tinnitus, and a headache disorder. Therefore, for these particular issues, the benefits sought on appeal have been granted in full. Accordingly, regardless of whether the notice and assistance requirements have been met with regard to these issues, no harm or prejudice to the Veteran has resulted. See, e.g., Bernard v. Brown, 4 Vet. App. 384 (1993); VAOPGCPREC 16-92. With regard to the remaining service connection issues for right ankle, low back, and neck disorders that are being denied in the present decision, review of the claims folder reveals compliance with VA's duty to notify by way of letters dated in January 2010, February 2017, and April 2017. 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017). See also Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances . . . we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran . . ."). With respect to the duty to assist, the RO has obtained the Veteran's service treatment records (STRs), service personnel records (SPRs), private medical evidence, and VA examinations. For his part, the Veteran has submitted personal statements, hearing testimony, a buddy statement, argument from his representative, and additional private medical evidence. Pursuant to the November 2016 Board remand, the Veteran in February 2017 provided medical authorization (VA Form 21-4142) to release records from the South Georgia Medical Center dated in the 1970 and 1980s. However, a February 2017 request from the RO to this private provider yielded a negative reply in March 2017. Specifically, the South Georgia Medical Center indicated it had no records of the Veteran from this time period as its retention policy is only for 10 years. The Board adds that it is common practice for hospitals and physicians to retain medical records for as long as required by law and then to destroy them. In this case, the Board is satisfied the RO has made reasonable efforts to obtain these private records. 38 C.F.R. § 3.159(c). In addition, the Veteran did not fill out any VA Form 21-4142 for private records from the 1990s, despite being prompted to do so by way of the VCAA letters mailed to him. He also failed to submit these records. In addition, various requests from the RO to secure Georgia Army National Guard medical and personnel records dated from 1982 to 1984 were met with negative replies throughout 2017 from the National Personnel Records Center (NPRC), the Records Management Center (RMC), the Georgia State Adjutant General, the Georgia Army National Guard Unit in question, and the Army Human Resources Command. In a July 2017 statement, the Veteran himself indicated that he did not have any of his Georgia Army National Guard records in his possession. VA is required to obtain "relevant" records held by any Federal department or agency that the claimant adequately identifies and authorizes VA to obtain. See 38 U.S.C. § 5103A(c)(3); 38 C.F.R. § 3.159(c)(2). In fact, VA must make as many requests as necessary to obtain "relevant" Georgia Army National Guard records, unless a determination is made that the records do not exist or that further efforts would be futile. 38 C.F.R. § 3.159(c)(2), (c)(3). In this case, the Board concludes that all procedures to obtain missing Georgia Army National Guard records dated from 1982 to 1984 were correctly followed, and that all efforts had been exhausted, such that further attempts would be futile. The Veteran was also afforded VA examinations and opinions in April 2017 that addressed the etiology of his alleged current right ankle, low back, and neck disorders. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4). It is acknowledged that in an April 2017 statement from the Veteran, he challenged the adequacy of these April 2017 VA examinations and opinions. The Federal Circuit has held that both the competence of a VA examiner and the adequacy of a VA examination and opinion are to be assumed unless challenged. Sickels v. Shinseki, 643 F.3d 1362, 1365-66 (Fed. Cir. 2011); Rizzo v. Shinseki, 580 F.3d 1288, 1291 (Fed. Cir. 2009). Here, the Veteran in an April 2017 statement has challenged the adequacy of the April 2017 VA examinations. Specifically, the Veteran alleged that the April 2017 VA physician was very hard to understand due to her accent and misuse of words. During the examination the Veteran says the VA examiner consistently addressed range of motion by using her hands to turn his head and back. The Veteran maintains he expressed his concerns about that being an invalid measure since a range of motion was in large part because of the use of her hands forcing the motion - that is, passive range of motion. The Veteran felt this type of assessment did not accurately indicate his limitations and that the VA examiner failed to fully address the major issues which were his constant aches and pains. The Veteran felt his symptoms were not seen with only a visual examination. The Veteran contends that several times during the range of motion checks the VA examiner would push and pull his body parts past what he could do with his own muscles. This caused him pain. During the examination concerning his right ankle the VA examiner shifted the problem to his toes. The Veteran did not comprehend this, because he has never had a problem, nor has been diagnosed with his toes being the cause of his pain. The Veteran added that the VA examiner attempted to guide his answers and talk past what he was trying to say, making it seem like the VA examiner was trying to skew and talk him out of his answers. However, the Board finds the April 2017 VA examinations and opinions were thorough, supported by explanations, based on a review of the claims folder, and supported by clinical evidence of record. They were also based on accurate clinical testing. The VA examinations also considered the Veteran's lay assertions. A history was solicited from the Veteran. The VA examiner addressed the central medical issues in this case and provided a rationale for her medical opinions. There is no probative support in the record that the April 2017 VA examinations were inaccurate or inadequate. Despite the Veteran's assertions regarding range of motion, the April 2017 VA ankle and spine examiner noted that "passive ROM was unchanged from active ROM and on repetitive testing..." Therefore, the April 2017 VA examiner correctly considered active range of motion for the respective joints, despite the Veteran's assertion to the contrary. In addition, the April 2017 VA examiner wrote that the VA examinations were "completed without incident." The VA examiner added that: The Veteran was given a chance to ask questions and receive answers. He was made aware of the diagnoses mentioned in these worksheets. He was asked if he had any questions / concerns / complaints about the exam and he said no. The next steps in the C&P process were explained to him and he expressed understanding. He departed the exam room ambulatory and in no distress. The April 2017 VA examiner's assessment of the VA examinations in question paints a different picture to the Veteran's allegations. The Veteran's subjective complaints have been considered by the Board, but are outweighed by the clear and adequate findings on the VA examination reports. As such, there is no persuasive basis for any further VA examination or opinion as to the right ankle, low back, and neck issues on appeal. The Veteran's service connection claims have been pending in the VA system for approximately eight years, and require prompt resolution. With regard to the June 2016 videoconference hearing testimony, the Veteran has not alleged any deficiency with his hearing testimony for the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). In this regard, the Federal Circuit ruled in Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) that a Bryant hearing deficiency was subject to the doctrine of issue exhaustion as laid out in Scott, supra. Thus, the Board need not discuss any potential Bryant problem, because neither the Veteran nor his representative has raised that issue before the Board. With regard to the previous November 2016 Board remand, a remand by the Board confers on the claimant a legal right to compliance with the remand order. Stegall v. West, 11 Vet. App. 268, 271 (1998). Failure of the Board to ensure compliance with remand instructions constitutes error and warrants the vacating of a subsequent Board decision. Id. However, only "substantial" compliance with the remand order, not strict compliance, is required. Donnellan v. Shinseki, 24 Vet. App. 167, 176 (2010); Dyment v. West, 13 Vet. App. 141, 147 (1999). In the present case, the Board has reviewed its previous November 2016 remand instructions, and finds that the RO has substantially complied with the Board's instructions. The Board is therefore satisfied that the RO has provided all assistance required by the VCAA. 38 U.S.C. § 5103A (2012). Hence, there is no error or issue that precludes the Board from addressing the merits of the service connection issues for the right ankle, low back, and neck disorders. II. Service Connection 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. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In addition, disorders diagnosed after discharge may also still be service-connected if all the evidence, including pertinent service records, establishes the disorder was incurred in service. 38 C.F.R. § 3.303(d). See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). As a general matter, service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Under 38 C.F.R. § 3.303(b), where the evidence shows an enumerated "chronic disease" in service (or within the presumptive period under § 3.307), or "continuity of symptoms" of such a disease after service, the disease shall be presumed to have been incurred in service. Walker v. Shinseki, 708 F.3d 1331, 1335-37 (Fed. Cir. 2013). Initially, the headache disorder, right ankle disorder, and low back and neck sprains / strains are not listed as an enumerated "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions based on "chronic" symptoms in service and "continuous" symptoms since service at 38 C.F.R. § 3.303(b) do not apply for these particular disorders. Walker, 708 F.3d at 1338-39. However, in the present case, sensorineural hearing loss and arthritis of any joint are an enumerated "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) would apply if sensorineural hearing loss or arthritis is noted or shown in the record. Walker, 708 F.3d at 1338-39. Moreover, the Court has also issued a decision adding tinnitus (as an organic disease of the nervous system) to the list of disabilities explicitly recognized as "chronic" in 38 C.F.R. § 3.309(a). See Fountain v. McDonald, 27 Vet. App. 258, 271 (2015). Service connection for an enumerated "chronic disease" such as sensorineural hearing and tinnitus and arthritis of the joints, listed under 38 C.F.R. § 3.309(a) can also be also be established on a presumptive basis by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). VA is to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). The Federal Circuit has held that medical evidence is not always or categorically required in every instance to establish a medical diagnosis or the required nexus between the claimed disability and the Veteran's military service. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). That is, lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology 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. Davidson, 581 F.3d at 1316. See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). In short, when considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent on the issues of diagnosis and medical causation. Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). "The question of whether a particular medical issue is beyond the competence of a layperson-including both claimants and [VA adjudicators] must be determined on a case-by-case basis. Id. Therefore, the Board must assess the competence and credibility of lay statements. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In adjudicating claims for VA benefits, the burden of proof only requires an "approximate balance" of the evidence for and against a claim. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1991). This low standard of proof is "unique" to the VA adjudicatory process, and "the nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding such benefits." Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) (citing Gilbert, 1 Vet. App. at 54). A. Hearing Loss and Tinnitus The Veteran has contended that he developed tinnitus and bilateral hearing loss as the result of noise exposure during service. Specifically, he has asserted that he was exposed to hazardous noise as the result of his military occupational specialty (MOS) as an infantryman and rifleman while serving from 1984 to 1988 with the U.S. Army. His DD Form 214 and service personnel records (SPRs) confirm that he did serve in this capacity. In particular, he indicates his MOS exposed him to hazardous noise exposure from loud guns. He says he "rarely" wore hearing protection during service. He testified he complained about hearing loss during service and tinnitus post-service in the mid-1990s. Post-service, he experienced noise exposure due to his career in construction for 20 years, but maintains that he wore hearing protection in this career as needed. According to VA standards, impaired hearing will be considered 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 these frequencies 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. Upon review of the evidence of record, the Board finds that service connection for bilateral hearing loss disability and tinnitus is warranted. As to the first requirement for a service-connection claim, the Veteran meets the criteria for proof of a current disability for both bilateral hearing loss and tinnitus. See 38 U.S.C. § 1131; Degmetich v. Brown, 104 F.3d 1328 (1997). Specifically, the April 2017 VA audiology examination reports revealed bilateral sensorineural hearing loss disability according to the clear, established requirements of 38 C.F.R. § 3.385. This audiology examination report also revealed current tinnitus. Thus, the existence of a current disability is undisputed for both of these issues on appeal. As to the second requirement of in-service incurrence, STRs dated from 1984 to 1988 are negative for any complaint, treatment, or diagnosis of tinnitus. Also, a diagnosis of hearing loss disability under § 3.385 was not present in either ear in the STRs. However, subsequent to noise exposure during active duty, a December 1984 STR audiogram revealed some diminished hearing in the right and left ears at 500, 4000, and 6000 Hertz. See Hensley v. Brown, 5 Vet. App. 155, 157 (1993) (higher threshold levels above 20 decibels may indicate some degree of hearing loss). Still, it is noted this level of diminished hearing in both ears in December 1984 did not meet the criteria for hearing loss disability as defined by VA under 38 C.F.R. § 3.385. Moreover, latter STR audiograms dated in 1987 and 1988 are negative for hearing loss disability under § 3.385 in either ear, and the Veteran's hearing threshold levels actually improved compared to the earlier December 1984 STR audiogram. But it is also acknowledged that in 1988 upon separation, in his report of medical history, the Veteran reported a history of hearing loss during his active service. In any event, with regard to an in-service injury, the Department of Defense's Duty MOS Noise Exposure Listing indicates that an MOS as an infantryman involved a "high" probability of noise exposure during service. In-service hazardous noise exposure is therefore consistent with the circumstances of the Veteran's duties in service. See 38 U.S.C. 1154(a); 38 C.F.R. 3.303(a). As to the third requirement of a nexus, post-service, the record is mixed. As early as June 2010, a VA TBI examination noted complaints of hearing loss and tinnitus bilaterally. The Veteran testified in June 2016 at his videoconference hearing that he first noticed tinnitus in the mid-1990s. In addition, a high school buddy who has known the Veteran for 39 years, submitted a May 2017 statement in which he credibly asserted that he noticed the Veteran's decline in his hearing and his complaints of tinnitus sometime after his separation from active duty in 1988. In contrast, an April 2017 VA audiology examiner opined that the Veteran's bilateral hearing loss and tinnitus are less likely as not due to military noise exposure, but more than likely impacted by post-service civilian noise exposure (i.e. construction work), presbycusis, and/or some other etiology. (The VA examiner did not specifically identify the precise etiology of the Veteran's hearing impairment and tinnitus, and the VA examiner did not address the Veteran's contention that he wore hearing protection as needed post-service). The VA examiner emphasized the Veteran's STR audiology examinations failed to establish bilateral sensorineural hearing loss disability according to the clear, established requirements of 38 C.F.R. § 3.385. But on this issue, in order for a claimant to establish service connection, it is not required that a hearing loss disability by the standards of 38 C.F.R. § 3.385 be demonstrated during service, although a hearing loss disability by the standards of 38 C.F.R. § 3.385 must be currently present, and service connection is possible if such current hearing loss disability can be adequately linked to service. Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). That is, a claimant may establish direct service connection for a hearing disability initially manifest several years after separation from service on the basis of evidence showing that the current hearing loss is causally related to injury or disease suffered in service. Hensley, 5 Vet. App. at 164. See also 38 U.S.C. 1113(b); 38 C.F.R. 3.303(d). Thus, the lack of evidence of tinnitus or bilateral hearing loss disability per § 3.385 during active service is not fatal to the Veteran's claims; it is merely one factor to be considered. The Board finds the Veteran and his buddy's lay assertions and hearing testimony both competent and credible as to his in-service and continuing post-service hearing loss symptoms, the development of his post-service tinnitus, as well as his in-service hazardous noise exposure and acoustic trauma. See 38 C.F.R. § 3.159(a)(2); Barr, 21 Vet. App. at 307-09. Although an etiological relationship has not been demonstrated through competent medical opinion evidence, the absence of a "valid medical opinion" is not an absolute bar to service connection, particularly where, as here, the lay evidence of record is sufficient to satisfy the final nexus prong. Davidson, 581 F.3d at 1316. Accordingly, resolving doubt in the Veteran's favor, the evidence supports service connection for tinnitus and bilateral hearing loss disability. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In granting the tinnitus and bilateral hearing loss disability claims, the Board once again emphasizes that the standard of proof is "unique" to the VA adjudicatory process, and "the nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding such benefits. Wise, 26 Vet. App. at 531 (citing Gilbert, 1 Vet. App. at 54). B. Headache Disorder The Veteran contends that he has headaches, dizziness, and numbness as the result of a TBI that occurred during active duty in June 1987. Specifically, in June 1987 he says he sustained an accident when he fell of a truck, hitting his head on a machine gun, causing a bump, knot, and swelling on his head. He experienced headaches and other symptoms at that time. He testified he was not unconscious at the time of the in-service TBI. Post-service, he did not seek medical treatment for his headaches. Rather, he self-treated his headaches, which occur 3-4 days a week. His headaches last for two hours. See June 2016 hearing testimony at pages 6-8, 14-16. Upon review of the evidence of record, the Board finds that service connection for a headache disorder as a residual of an in-service TBI is warranted. As to the first requirement for a service-connection claim, the Veteran meets the criteria for proof of a current disability for a headache disorder. See 38 U.S.C. § 1131; Degmetich v. Brown, 104 F.3d 1328 (1997). As to medical evidence, VA TBI examiners in June 2010 and March 2017 diagnosed the Veteran with a headache disorder. And as a lay person, the Veteran and his buddy have also competently and credibly described his frequent symptoms of headaches. Barr, 21 Vet. App. at 308. Thus, the evidence of record reveals a current headache disorder. Due to underlying in-service TBI the Veteran sustained (see June 1987 STR), as documented in the record, the Board has specifically considered the presumptive provisions 38 C.F.R. § 3.310(d). Under 38 C.F.R. § 3.310(d), in a veteran who has a service-connected TBI, the following shall be held to be the proximate result of the service-connected TBI, in the absence of clear evidence to the contrary: (i) Parkinsonism, including Parkinson's disease, following moderate or severe TBI; (ii) Unprovoked seizures following moderate or severe TBI; (iii) Dementias of the following types: presenile dementia of the Alzheimer type, frontotemporal dementia, and dementia with Lewy bodies, if manifest within 15 years following moderate or severe TBI; (iv) Depression if manifest within 3 years of moderate or severe TBI, or within 12 months of mild TBI; or (v) Diseases of hormone deficiency that result from hypothalamo-pituitary changes if manifest within 12 months of moderate or severe TBI. Thus 38 C.F.R. § 3.310(d)(1) entails presumptive service connection for the above disabilities. However, the Veteran's currently diagnosed headache disorder is not listed under 38 C.F.R. § 3.310(d)(1) as one of the presumptive conditions associated with a TBI injury. Nonetheless, secondary service connection may also be awarded under 38 C.F.R. § 3.310(d)(2) for any condition not meeting the above criteria, under the generally applicable provisions of service connection. This would entail consideration of non-presumptive service connection, established by the evidence of record. Therefore, the Board will consider the Veteran's headache disorder on a non-presumptive basis as well. The determination of the severity level (mild, moderate, or severe) of the underlying TBI is based on the TBI symptoms at the time of the injury or shortly thereafter. The TBI does not have to meet all the criteria listed under a certain severity level in order to classify the TBI at that severity level. If a TBI meets the criteria in more than one category of severity, then the TBI should be ranked at the highest level in which a criterion is met, except where the qualifying criterion is the same at both levels. 38 C.F.R. § 3.310(d)(3). A TBI is mild in severity if there is normal structural imaging, loss of consciousness for up to 30 minutes, alteration of consciousness or mental statement for a moment to up to 24 hours, post-traumatic amnesia for up to a day, and a Glasgow Coma Scale ranging from 13 to 15. A TBI is moderate in severity if there is normal or abnormal structural imaging, loss of consciousness from 30 minutes to less than 24 hours, alteration of consciousness or mental state for more than 24 hours, post-traumatic amnesia from one to 7 days, or Glasgow Coma Scale from 9-12. A TBI is severe if there is normal or abnormal structural imaging, loss of consciousness for more than 24 hours, alteration of consciousness or mental state for more than 24 hours, post-traumatic amnesia for more than 7 days or a Glasgow Coma Scale of 3-8. See 38 C.F.R. § 3.310(d)(3). The resultant disabling effects of a TBI event beyond those that follow immediately from the acute injury to the brain are known as TBI residuals or TBI sequelae. The signs and symptoms of TBI residuals can be organized into the three main categories of physical, cognitive, and behavioral / emotional residuals for evaluation purposes. TBI residuals can resolve in a short period of time, persist chronically or permanently, or may also have a delayed onset. Notably, "headaches", "dizziness", and "sensory loss" are listed as examples of known TBI residuals, in the "physical" residual category in a VA table contained in the Live Manual. See M21-1, Live Manual, Part III, Subpart iv, Chapter 4, Section G, Topic 2, Block d (change date September 29, 2016). As to the second requirement of in-service incurrence, a June 1987 STR shows a complaint of a bump on top of the Veteran's head. It was noted he hit his head several months earlier. His head bump went down, but started to come back. He reported headaches, fever, dizziness, and numbness of the left leg. The June 1987 STR noted no loss of consciousness when the Veteran previously hit his head. Instead, he felt weak and nauseated at the time. On examination in June 1987, there was no swelling or tenderness on the scalp. His motor and sensory were within normal limits. His reflexes were within normal limits. With regard to the in-service TBI documented in June 1987, after review of the medical and lay evidence of record (see e.g., June 2010 VA TBI examination), the Veteran's in-service June 1987 TBI injury was classified as "mild" due to no loss of consciousness alteration of consciousness or mental state for more than 24 hours. See 38 C.F.R. § 3.310(d)(3). Upon separation in 1988, the Veteran denied any frequent or severe headaches. As to the third requirement of a nexus, post-service, the record is mixed. A March 2017 VA TBI examiner proffered a negative opinion with regard to a nexus. An earlier June 2010 VA examiner was inconclusive in his final opinion. In any event, both the June 2010 and March 2017 VA TBI examiners failed to address the Veteran's documented in-service headaches. The Court has held that a medical examiner's conclusions were of "questionable probative value" when the examiner failed to consider certain relevant information. Mariano v. Principi, 17, Vet. App. 305, 312 (2003). The focus is not on whether the clinician had access to the claims file, but instead on whether the clinician was "informed of the relevant facts" and medical history in rendering a medical opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In contrast, with regard to lay evidence of a nexus to the in-service TBI, a high school buddy who has known the Veteran for 39 years submitted a May 2017 statement in which he credibly asserted that shortly after his discharge from service in 1988, the Veteran complained about his head hurting "like a headache" and he needed to go lay down. Post-service, the Veteran and his buddy are competent as lay persons to report continuing symptoms for headaches after his military service. Layno, 6 Vet. App. at 469. See also 38 C.F.R. § 3.159(a)(2); Pierce v. Principi, 18 Vet. App. 440 (2004) (lay evidence may can be probative of frequency, prolongation, and severity of headaches). Moreover, both are also credible in their report of the Veteran's headaches continuing intermittently after his military service, becoming progressively worse over time. See Barr v. Nicholson, 21 Vet. App. 303 at 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible and probative). The Veteran has been forthright that he self-medicated for a long time and did not seek medical treatment post-service for his headaches. The Board emphasizes that to establish a nexus, there is no requirement that a Veteran seek post-service medical treatment for a headache condition. The mere absence of medical records does not contradict a Veteran's statements about his symptom history. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). And although an etiological relationship has not been demonstrated through competent medical opinion evidence, the absence of a "valid medical opinion" is not an absolute bar to service connection, particularly where, as here, the lay evidence of record is sufficient to satisfy the final nexus prong. Davidson, 581 F.3d at 1316. Accordingly, resolving doubt in the Veteran's favor, the evidence supports service connection for a headache disorder as a residual of an in-service TBI. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In granting the headache disorder claim, the Board once again emphasizes that the standard of proof is "unique" to the VA adjudicatory process, and "the nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding such benefits. Wise, 26 Vet. App. at 531 (citing Gilbert, 1 Vet. App. at 54). On a side note, with regard to the Veteran's reported dizziness and numbness, the June 2010 VA TBI examiner found no evidence of current dizziness or current numbness attributable to the verified in-service TBI. In fact, neither dizziness nor numbness nor a medical condition related thereto was found upon objective neurological examination in June 2010. Therefore, service connection is not warranted for either dizziness or numbness as an alleged TBI residual. C. Right Ankle Disorder The Veteran contends that his right ankle problems began during active duty in March 1984 and November 1985. He says he was treated in-service on multiple occasions for his right ankle. As part of his physical training as an infantryman, in March 1984 he says he hurt his right ankle in airborne jump school when jumping from a training tower. He states that his right ankle has been an intermittent but persistent problem with chronic instability ever since active duty from 1984 to 1988. Post-service, he adds he was first treated in the 1990s, but that thereafter he self-treated the right ankle pain with over-the-counter medicine. See December 2009 claim; February 2013 VA Form 9; June 2016 hearing testimony at pages 3-5, 12-13; April 2010 VA ankle examination. Initially, as noted above, the right ankle sprain / strain / instability issue on appeal is not an enumerated "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions based on "chronic" symptoms in service and "continuous" symptoms since service at 38 C.F.R. § 3.303(b) do not apply in the present case for the right ankle. Walker, 708 F.3d at 1338-39. Upon review of the evidence of record, the Board concludes that the Veteran is not entitled to service connection for a right ankle disorder. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1131; Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, in an April 2010 VA ankle examination, the Veteran was diagnosed with a right ankle sprain with instability. In addition, a latter April 2017 VA ankle examiner diagnosed the Veteran with a "resolved" ankle sprain, with no objective evidence of chronic residuals. There is no further treatment for the right ankle in the record. In any event, the Board has considered that the requirement of a current disability is fulfilled if a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). It follows that the Veteran clearly had a right ankle diagnosis during the course of the appeal, and the remaining question is whether any right ankle disorder he has initially manifested in service or is otherwise related thereto. With regard to the issue of aggravation of a right ankle condition that preexisted entry into service, the Veteran's STRs reveal that at his January 1984 report of medical history upon enlistment, the Veteran reported a history of foot trouble. There was a notation about a prior right ankle repair surgery. At his January 1984 enlistment examination, a right ankle scar was clinically noted, with an otherwise normal examination of the lower extremities. However, in a February 2017 statement and at the April 2017 VA ankle examination, the Veteran clarified that he did not have right ankle surgery prior to enlistment into service in 1984. There was no preexisting right ankle orthopedic disability reported by the Veteran. Prior to 1984, the Veteran visited the South Georgia Medical Center only because he had a cut on his right ankle, for which he required stitches in the emergency room. This cut left a scar on his right ankle, which was noted at his enlistment examination. But prior to 1984, there was no right ankle surgery for an orthopedic or joint condition. Since evidence of a right ankle scar was noted at the time of the Veteran's entrance into service, the Veteran is not entitled to the presumption of soundness for a right ankle scar when entering service. See 38 U.S.C. §§ 1111, 1132, 1137; 38 C.F.R. § 3.304(b). Rather, since there is evidence of a preexisting right ankle scar noted at entrance, it is the Veteran's burden to show a chronic (meaning permanent) worsening of his preexisting right ankle scar during service. In other words, the Veteran may only bring a claim for aggravation of this preexisting right ankle scar. Wagner, 370 F.3d at 1096. A preexisting injury or disease will be considered to have been aggravated during service when there is an increase in disability during service, unless there is a specific finding (by clear and unmistakable evidence) that the increase in disability is due to the natural progression of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). However, the Veteran and his representative have not contended, nor does the clinical evidence show, that the preexisting right ankle scar was aggravated by his military service. In fact, the April 2017 VA ankle examiner, after observing the Veteran's right ankle scar, concluded that there is no evidence of aggravation of any preexisting right ankle condition during the Veteran's military service from 1984 to 1988. As such, the Board finds no evidence of worsening of the Veteran's preexisting right ankle scar during his military service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). See also Wagner v. Principi, 370 F.3d 1089, 1094- 1096 (Fed. Cir. 2004). As such, this issue warrants no further discussion. With regard to in-service incurrence, the Veteran's STRs reveal that in March 1984, he sustained an injury to the right ankle and right calf. He was seen twice. The diagnosis was contusion and muscular pain. Tenderness was noted. A November 1985 STR documented bilateral leg pain of five days duration. There was an ace bandage to the legs. Tenderness was observed. The diagnosis was a strain to the posterior tibialis. But most importantly, at the 1988 STR separation examination, the Veteran's lower extremities were assessed as normal, and no ankle problems were reported by the Veteran. In fact, the Veteran denied any leg or lower extremity problems. Thus, although STRs reveal in-service treatment for the right ankle, the 1988 separation examination failed to assess any residual right ankle disability. Post-service, with regard to any potential allegation of continuity of symptomatology, the Federal Circuit has held that only those chronic diseases listed in 38 C.F.R. § 3.309 are subject to service connection by way of continuity of symptoms as described in § 3.303(b). See again Walker, 708 F.3d at 1340. In this vein, the Veteran's right ankle problems are not listed as one of those chronic diseases such as arthritis, such that service connection in the present case would not be available for continuity of symptoms of any right ankle disorder. However, post-service, to offer the Veteran every benefit of the doubt, the Board has considered whether the Veteran has had frequent or persistent or ongoing or residual symptoms of a right ankle disorder, continuing after his separation from the Army in 1988. That is, in a May 2017 buddy statement, the Veteran's high school friend indicated that prior to his starting his starting his own business as a handyman and later receiving his contractor license, the Veteran complained about his ankles. In addition, the Veteran testified under oath that his first post-service treatment for his right ankle was with a private provider in the 1990s. See June 2016 videoconference hearing. The Veteran did not provide medical authorization for VA to secure these records from the 1990s, despite providing medical authorization for other private records during the course of the appeal. At the April 2010 VA ankle examination, the Veteran reported chronic instability in the right ankle since the time of his military service. In any event, the Veteran and his friend are competent to report observable ankle symptoms such as pain or discomfort, beginning in the 1990s. Layno, 6 Vet. App. at 469. See also 38 C.F.R. § 3.159(a)(2). However, once evidence is determined to be competent, the Board must determine whether the evidence also is also credible. The former, the Court has held, is a legal concept, which is useful in determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (emphasis added). Definitions of credibility do not necessarily confine that concept to the narrow peg of truthfulness. Indiana Metal Prods. v. NLRB, 442 F.2d 46, 52 (7th Cir. 1971). Credibility has been termed as "the quality or power of inspiring belief." Webster's Third New International Dictionary (1966). "Credibility involves more than demeanor. It apprehends the over-all evaluation of testimony in the light of its rationality or internal consistency and the manner in which it hangs together with other evidence." Carbo v. United States, 314 F.2d 718, 749 (9th Cir. 1963). That is, the Board must determine, as a question of fact, both the weight and credibility of the evidence. Equal weight is not accorded to each piece of evidence contained in a record; every item does not have the same probative value. The Board must analyze the credibility and probative value of all material evidence submitted by and on behalf of a claimant, account for the evidence that it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Struck v. Brown, 9 Vet. App. 145, 152 (1996); Caluza v. Brown, 7 Vet. App. 498, 506 (1995); Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994); Abernathy v. Principi, 3 Vet. App. 461, 465 (1992); Simon v. Derwinski, 2 Vet. App. 621, 622 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164, 169 (1991). The Veteran's credibility affects the weight to be given to his or her testimony and lay statements, and it is the Board's responsibility to determine the appropriate weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, the demeanor of the witness, the facial plausibility of the testimony, the internal consistency of the testimony, impairment in memory, or, to a certain extent, bad character, among other factors. Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In particular, personal interest may affect the credibility of the evidence. Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991). The Board cannot determine that lay evidence lacks credibility solely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). Symptoms, not treatment, are the important factor. See Cartright v. Derwinski, 2 Vet. App. 24, 26 (1991). The Board may, however, weigh a lack of contemporaneous medical evidence as one factor, among others, that the Board can consider and weigh against lay evidence. Buchanan, 451 F.3d at 1337. That is, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). In this regard, post-service, the most probative, credible evidence of record fails to document any frequent or persistent symptoms or complaints of any right ankle problems until 2009, which is 21 years after separation from service. The Veteran's lay assertions as to ongoing right ankle symptoms after the confirmed in-service right ankle treatment are inconsistent with the totality of the evidence of record, and entitled to less probative weight, for the following reasons: First, as noted above, the 1988 STR separation examination failed to assess any residual right ankle disability. This is an objective clinical determination. Furthermore, no right ankle problems were reported by the Veteran at separation in 1988. Second, some post-service medical evidence is inconsistent with the Veteran's lay assertions regarding right ankle treatment and continuing symptoms in the 1990s. See Gardin v. Shinseki, 613 F.3d 1374, 1379 (Fed. Cir. 2010); Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (the Board can use inconsistent statements, among other factors, to impeach the credibility of a witness). For example, upon interview at the April 2017 VA ankle examination, the Veteran reported he has had a family doctor since 1995 until 2010, another doctor since 2010 until the current time, for his yearly physical. The Veteran stated, "[h]owever no specific treatment or care for the right ankle was ever required or given. I know to self-treat it." The Veteran continued that after he received treatment for his right ankle during service, there was "no further ankle treatment since then." He added that he has been running 5K races from 1984 to 2016, but he has had "no issues." He has good footwear for running. This April 2017 VA ankle examination generated for the purposes of medical treatment may be afforded greater probative value because there is a strong motive to tell the truth in order to receive proper care at the time. Rucker v. Brown, 10 Vet. App. 67, 73 (1997). With regard to post-service right ankle symptoms and treatment, the Board must first establish a proper foundation for drawing inferences against a claimant from an absence of documentation. Fountain v. McDonald, 27 Vet. App. 258 (2015). In this regard, the Veteran's statements in the medical evidence above, made for the purpose of medical diagnosis or treatment, are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment. White v. Illinois, 502 U.S. 346, 355-56 (1991); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that, although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate). Third, in light of the Veteran's inconsistent statement when compared to the clinical evidence discussed in detail above, it can be argued there is interest and bias in the Veteran's contentions related to his right ankle claim for VA benefits. See Cartwright v. Derwinski, 2 Vet. App. 24, 25-26 (1991) (a pecuniary interest may affect the credibility of a claimant's lay testimony). Post-service, with regard to a nexus, there is probative medical evidence of record that clearly weighs against a relationship between his current right ankle disorder with any injury or treatment from his period of military service. Holton, 557 F.3d at 1366. See also 38 C.F.R. § 3.303(a), (d). In fact, the Veteran has submitted no probative medical evidence of a nexus. Absent such evidence of a nexus, service connection is not in order for the Veteran's right ankle problems. Specifically, the April 2010 VA ankle examiner opined that "[i]t is less likely as not" that the Veteran's claimed right ankle condition is the result of the injuries he suffered while in the military. The VA examiner reasoned that there is no indication of chronic or severe injuries to the right ankle in the STRs. There are also no post-service records available to show chronic right ankle problems either. The Veteran does have right ankle instability. But the origin of this right ankle instability is unclear, according to the VA examiner. The VA examiner added that the STRs for the right ankle pertain to tendinitis and to calf pain, but not to instability. Moreover, a separate April 2017 VA ankle examiner assessed that the Veteran's earlier ankle sprain from 2010 had resolved, with no objective evidence of chronic residuals. The VA examiner observed a normal right ankle examination with full range of motion. Currently, the Veteran's right ankle is asymptomatic. Thus, the VA examiner found that the right ankle sprain was a "transient" condition that had resolved without objective evidence of chronic residuals. There was no further treatment for the right ankle since 2010. The Veteran stated he has twisted and turned his right ankle several times over the years since his military service. As discussed above, the Veteran reported to the VA examiner he has had a family doctor since 1995 until 2010, another doctor since 2010 until the current time, for his yearly physical. The Veteran stated, "[h]owever no specific treatment or care for the right ankle was ever required or given. I know to self-treat it." The Veteran continued that after he received treatment for his right ankle during service, there was "no further ankle treatment since then." He added that he has been running 5K races from 1984 to 2016, but he has had "no issues." He has good footwear for running. The Veteran reported that after discharge from the military in 1988 he did construction for 20 years. The April 2017 VA ankle examiner concluded that based on review of the available medical records, medical literature, and clinical experience, "it is less likely as not (less than 50/50 probability)" that any current right ankle disorder is causally or etiologically related to the Veteran's military service from 1984 to 1988, including any treatment therein. The VA examiner discussed the Veteran's muscular pain and contusion and strain of the post-tibial muscle in STRs dated in March 1984 and November 1985 during active duty service. In contrast, the April 2010 VA ankle examiner diagnosed right ankle sprain with instability. At present in April 2017, the VA examiner observed the Veteran's right ankle to be normal. The Veteran has had no significant ongoing right ankle issues, since he uses the protective foot wears for his 5K events he runs in over the years. There is no contrary medical opinion of record. With regard to lay evidence of a nexus of a current right ankle disorder to the Veteran's active service, the Federal Circuit has held that lay persons are not categorically incompetent to speak on matters of medical diagnosis or etiology. Davidson, 581 F.3d at 1316. In this vein, the Board must consider the type of condition specifically claimed and whether it is readily amenable to lay diagnosis or probative comment on etiology. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Veteran is indeed competent to report purported symptoms of a right ankle disorder during and after service. See 38 C.F.R. § 3.159(a)(2); Barr, 21 Vet. App. at 307-09. That notwithstanding, the Veteran's lay assertions in the present case are outweighed by the clinical evidence of record, which is sometimes inconsistent with the Veteran's lay assertions. The Federal Circuit has held that the Board can favor competent medical evidence over lay statements offered by the Veteran, as long as the Board neither deems lay evidence categorically incompetent nor improperly requires a medical opinion as the sole way to prove causation. King v. Shinseki, 700 F.3d 1339, 1344 (2012). The Board adds the Veteran is not competent to medically link his post-service right ankle disorder with his in-service treatment for the right ankle, as this would require medical training, knowledge, and expertise. Accordingly, the preponderance of the evidence is against the Veteran's service connection claim for a right ankle disorder. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). D. Low Back Disorder The Veteran contends that he has a low back disorder related to his documented April 1986 fall on a trailer hitch during active duty, or his MOS duties as an infantryman. Post-service, the Veteran maintains that he has experienced frequent and persistent or ongoing low back symptoms since 1990, with his first post-service treatment in the 1990s. He adds he has been diagnosed with degenerative joint disease of the low back, but he has not submitted these records, nor authorized VA to secure them. See April 2010 VA spine examination report; June 2016 videoconference hearing at pages 5-6, 12-13. Upon review of the evidence of record, the Board concludes that the Veteran is not entitled to service connection for a low back disorder. As mentioned above, the first and perhaps most fundamental requirement for any service-connection claim is proof the veteran currently has the claimed disability. 38 U.S.C. § 1131; Boyer, 210 F.3d at 1353; Brammer, 3 Vet. App. at 225. Here, the April 2010 VA spine examiner diagnosed the Veteran with a lumbosacral strain. In addition, private treatment records from Care Medical Center dated from October 2012 to January 2013 diagnosed the Veteran with lumbar strains / sprains. The Veteran participated in chiropractic care. Finally, the April 2017 VA spine examiner diagnosed the Veteran with a lumbosacral strain, a transient condition, which resolved without objective evidence of chronic residuals. In any event, the evidence clearly reveals a low back disability for the Veteran during the course of the appeal. The remaining is whether his low back disorder manifested in service or is otherwise related thereto. With regard to in-service evidence, an April 1986 STR noted pain in the left lower back above the kidney. There was an injury due to a fall on a trailer hitch. Pain was present for five days. The diagnosis was a "low back injury." Slight edema was observed. The Veteran was given aspirin to take every two hours. All remaining STRs dated from 1984 to 1988 are negative for any complaints, treatment, or diagnosis of a low back disorder. Importantly, at his 1988 STR report of medical history at separation, the Veteran denied a history of recurrent back pain, arthritis, or neuritis. Moreover, upon examination in 1988 at separation, his spine was observed to be normal. Therefore, there is no evidence of a chronic low back disorder during service, such as arthritis. However, his reported in-service history of parachute jumps and physical training as part of his MOS duties as an infantryman appears credible and consistent with the places, types, and circumstances of the Veteran's service in the Army. 38 U.S.C.A. § 1154(a); 38 C.F.R. § 3.303(a). His DD Form 214 and SPRs confirm he served in this capacity. Post-service, the Board acknowledges the Veteran's assertion that a private medical provider has diagnosed him with low back and neck degenerative joint disease or arthritis in 2011, based on X-rays. See April 2017 VA spine examination report. However, the Veteran told the April 2017 VA spine examiner that nothing can be done for his low back arthritis, so there is no need to repeat X-rays. The Veteran added he will try to find the X-ray report himself to send to the VA. (The record does not show that the Veteran sent in X-rays of the low back or neck to the VA.) The April 2017 VA spine examiner remarked that considering the age of the Veteran at that time - (52 years of age), age-related DJD is a possibility. The VA examiner added he would be happy to review the X-rays when available. The VA examiner also indicated that the examination report should not be considered insufficient as the Veteran declined X-rays to confirm his self-reported DJD / arthritis of the low back. In any event, lay testimony regarding what a medical professional tells a lay person is specifically listed as one of the examples given as competent lay testimony. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran is competent to relate that a medical professional diagnosed him with arthritis of the low back or neck based on X-rays. Regardless, the April 2017 VA spine examiner assessed that any possibility of arthritis of the low back for the Veteran would be "age-related." There was no mention of a nexus to service. Post-service, the Board has considered whether the Veteran has had frequent or persistent or ongoing symptoms of the low back after his separation from service in 1988. In this regard, the Veteran maintains that he has experienced frequent and persistent or ongoing low back symptoms since 1990, with his first post-service treatment in the 1990s. He adds he has been diagnosed with degenerative joint disease of the low back, but he has not submitted these records, nor authorized VA to secure them. See April 2010 VA spine examination report; June 2016 videoconference hearing at pages 5-6, 12-13. Also in a May 2017 buddy statement, the Veteran's high school friend indicated that prior to his starting his own business as a handyman and later receiving his contractor license, the Veteran complained about his backaches. In any event, the Veteran and his friend are competent to report observable low back symptoms such as pain or discomfort, beginning in the 1990s. Layno, 6 Vet. App. at 469. See also 38 C.F.R. § 3.159(a)(2). However, these lay assertions of ongoing low back symptoms from the time of service are outweighed by other probative evidence of record. The mere absence of medical records does not contradict a Veteran's statements about his symptom history. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board may weigh the absence of contemporaneous medical evidence of a low back disorder until 2010 (approximately 22 years after service) against the lay evidence of record in determining credibility. Id. at 1337. See also Maxson, 230 F.3d at 1333. Specifically, at his 1988 STR report of medical history at separation, the Veteran denied a history of recurrent back pain, arthritis, or neuritis. Moreover, upon examination in 1988 at separation, his spine was observed to be normal. In addition, private treatment records from Care Medical Center dated from October 2012 to January 2013 diagnosed the Veteran with lumbar strains / sprains which were "acute" in nature with an onset of approximately July 2012 after a motorcycle accident. There was no mention of a relationship to his military service in these private records. Finally, in his reported history and interview with the April 2017 VA spine examiner, the Veteran did not discuss any medical treatment for his low back between the time of separation from service in 1988 until 2010. The Veteran's history given to the VA examiner reported there was "no" need for medical care or treatment several years since his discharge from the military in 1988. This evidence, taken as a whole, is inconsistent with the Veteran's other lay assertions regarding low back treatment and continuing symptoms in the 1990s. See again Gardin v. Shinseki, 613 F.3d 1374, 1379 (Fed. Cir. 2010); Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (the Board can use inconsistent statements, among other factors, to impeach the credibility of a witness). With regard to a nexus, there is probative medical evidence of record that clearly weighs against a relationship between the Veteran's present low back problems and his period of military service. Holton, 557 F.3d at 1366. See also 38 C.F.R. § 3.303(a), (d). Specifically, the Veteran was afforded a VA examination in April 2010. The VA examiner discussed the Veteran's in-service treatment for low back pain and a trailer hitch injury in April 1986. The VA examiner opined "[i]t is less likely as not" that the Veteran's lumbar spine strain is the result of the injuries he suffered while in the military. The VA examiner reasoned there is no indication of chronic or severe injuries to the lumbar spine in the STRs. There are also no post-service records available to show chronic lumbar spine problems either. The Board finds this VA examination is somewhat flawed as the VA examiner did not appear to weigh the Veteran's reported lay history of ongoing low back pain since the time of his military service. The Veteran was afforded another VA spine examination in April 2017. Upon examination of the low back, the VA examiner rendered a diagnosis of a normal lumbar spine with full range of motion. The VA examiner found it was "more appropriate" to diagnose "[l]umbosacral strain, a transient condition - resolved without objective evidence of chronic residuals." The VA examiner opined "[i]t is less likely as not (less than 50/50 probability) that any current low back disorder began during service or is otherwise related to any incident of service, to include the Veteran's documented April 1986 fall on a trailer hitch, or his MOS duties as an infantryman. The rationale of the VA examiner was that based on a review of the available medical records, medical literature, and clinical experience, one STR shows the Veteran was seen once for a "transient" "low back injury" in April 1986. There was no evidence of chronicity in the military or several years following discharge from the military. The Veteran's oral history given to the VA examiner was a factor in this opinion, as the Veteran reported there was "no" need for medical care or treatment several years since his discharge from the military in 1988. The VA examiner added that the Veteran's current self-reported symptoms are more consistent with his poor posture and need for chiropractor therapy. Importantly, the Veteran has not submitted any contrary medical opinion of record with regard to his low back. The April 2010, and especially the April 2017 VA spine examinations and opinions weigh heavily against the service connection claim for a low back disorder. With regard to lay evidence of a nexus of a current low back disorder to the Veteran's active service, the Federal Circuit has held that lay persons are not categorically incompetent to speak on matters of medical diagnosis or etiology. Davidson, 581 F.3d at 1316. In this vein, the Board must consider the type of condition specifically claimed and whether it is readily amenable to lay diagnosis or probative comment on etiology. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Veteran is indeed competent to report purported symptoms of low back pain during and after service. See 38 C.F.R. § 3.159(a)(2); Barr, 21 Vet. App. at 307-09. However, neither the Veteran nor his representative has medical training or expertise for offering a medical nexus opinion as to a low back strain or sprain. See 38 C.F.R. § 3.159(a)(1)-(2); Jandreau, 492 F.3d at 1377. That is, as to the Veteran's lay assertions with regard to nexus, he does not meet any of the three exceptions for competent lay evidence as listed under Jandreau. The Veteran has never indicated that any medical professional offered a nexus opinion for his low back. Furthermore, the Veteran's lay assertions in the present case are outweighed by the clinical findings of the April 2017 VA spine examiner, who determined that the Veteran did not have a current low back disorder originating during service. The Federal Circuit has held that the Board can favor competent medical evidence over lay statements offered by the Veteran, as long as the Board neither deems lay evidence categorically incompetent nor improperly requires a medical opinion as the sole way to prove causation. King, 700 F.3d at 1344. In this case, the April 2017 VA spine examiner reviewed and considered the evidence of record, including the Veteran's lay statements, and provided a medical opinion with a supporting rationale relying on medical training, knowledge, and expertise. Accordingly, the preponderance of the evidence is against the Veteran's service connection claim for a low back disorder. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). E. Neck Disorder The Veteran contends that he has a neck disorder related to his documented April 1986 fall on a trailer hitch during active duty, or his MOS duties as an infantryman. He says he hurt his neck at the time of the injury, not just his low back. Post-service, the Veteran maintains that he has experienced frequent and persistent or ongoing neck symptoms since 1990, with his first post-service treatment in the 1990s. See December 2009 service connection claim; February 2013 VA Form 9; April 2010 VA spine examination report; June 2016 videoconference hearing at pages 5-6. Upon review of the evidence of record, the Board concludes that the Veteran is not entitled to service connection for a neck disorder. As mentioned above, the first and perhaps most fundamental requirement for any service-connection claim is proof the veteran currently has the claimed disability. 38 U.S.C. § 1131; Boyer, 210 F.3d at 1353; Brammer, 3 Vet. App. at 225. Here, the April 2010 VA spine examiner diagnosed the Veteran with a cervical strain. In addition, private treatment records from Care Medical Center dated from October 2012 to January 2013 diagnosed the Veteran with cervical strains / sprains and cervicalgia. The Veteran participated in chiropractic care. Finally, the April 2017 VA spine examiner diagnosed the Veteran with a cervical strain, a transient condition, which resolved without objective evidence of chronic residuals. In any event, the evidence clearly reveals a neck disability for the Veteran during the course of the appeal. The remaining issue is whether his neck disorder manifested in service or is otherwise related thereto. An April 1986 STR noted an injury due to a fall on a trailer hitch. However, there is no indication in this STR record the Veteran hurt his neck at that time - instead, he received treatment for the low back. When a medical condition or symptom has not been noted in the medical records, the Board may not consider that as negative evidence unless it is the sort of condition or symptom that would normally be noted or reported. See Buczynski v. Shinseki, 24 Vet. App. 221, 226-27 (2011). The Board finds that a neck injury from a fall on a trailer hitch in April 1986 is not something that ordinarily would simply be ignored by or not reported to military medical personnel, especially since the Veteran did report a low back injury in April 1986 at that time. Accordingly, the Board finds the Veteran's lay assertions regarding an in-service neck injury in April 1986 are not credible; thus, these assertions are not probative. See Barr, 21 Vet. App. at 308 (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). Significantly, all remaining STRs dated from 1984 to 1988 are negative for any complaints, treatment, or diagnosis of a neck disorder. Importantly, at his 1988 STR report of medical history at separation, the Veteran denied a history of recurrent back pain, arthritis, or neuritis. Moreover, upon examination in 1988 at separation, his neck was observed to be normal. Therefore, there is no probative evidence of any neck disorder or injury to the neck during service in the STRs. Post-service, the Board has considered whether the Veteran has had frequent or persistent or ongoing symptoms of the neck after his separation from service in 1988. The Veteran maintains he has experienced ongoing neck symptoms since service. See June 2016 videoconference hearing at pages 5-6. However, these lay assertions of ongoing neck symptoms from the time of service are outweighed by other probative evidence of record. The analysis in this regard is virtually identical to the analysis above for the low back. That is, upon examination in 1988 at separation, his neck was observed to be normal. The Veteran was first treated for a cervical strain at an April 2010 VA spine examination. In addition, private treatment records from Care Medical Center dated from October 2012 to January 2013 diagnosed the Veteran with neck strains / sprains and cervicalgia which were "acute" in nature with an onset of approximately July 2012 after a motorcycle accident. There was no mention of a relationship to his military service in these private records. Finally, in his reported history and interview with the April 2017 VA spine examiner, the Veteran did not discuss any medical treatment for his neck between the time of separation from service in 1988 until 2010. The Veteran reflected that his neck problems were due to wear and tear over the years and that he sustained no known upper back or neck injury. The Veteran's history given to the VA examiner reported there was "no" need for medical care or treatment several years since his discharge from the military in 1988. This evidence, taken as a whole, is inconsistent with the Veteran's other lay assertions regarding neck treatment and continuing symptoms in the 1990s. See again Gardin v. Shinseki, 613 F.3d 1374, 1379 (Fed. Cir. 2010); Caluza v. Brown, 7 Vet. App. 498, 510-511 (1995) (the Board can use inconsistent statements, among other factors, to impeach the credibility of a witness). With regard to a nexus, there is probative medical evidence of record that clearly weighs against a relationship between the Veteran's current neck problems and his period of military service. Holton, 557 F.3d at 1366. See also 38 C.F.R. § 3.303(a), (d). The Veteran was afforded a VA spine examination in April 2017. Upon examination of the neck, the VA examiner rendered a diagnosis of a normal cervical spine with full range of motion. The VA examiner found it was "more appropriate" to diagnose "[c]ervical strain, a transient condition - resolved without objective evidence of chronic residuals." The VA examiner opined "[i]t is less likely as not (less than 50/50 probability)" that any current neck disorder began during service or is otherwise related to any incident of service, to include the Veteran's documented April 1986 fall on a trailer hitch, or his MOS duties as an infantryman. The rationale of the VA examiner was that based on a review of the available medical records, medical literature, and clinical experience, STRs dated from 1984 to 1988 are silent for any evaluation, care, or treatment of the neck. There was no evidence of ongoing neck issues in the military or several years following discharge from the military. The Veteran's oral history given to the VA examiner was a factor in this opinion, as the Veteran reported there was "no" need for medical care or treatment several years since his discharge from the military in 1988. The VA examiner added that the Veteran's current self-reported symptoms are more consistent with his poor posture. Importantly, the Veteran has not submitted any contrary medical opinion of record with regard to his neck. The April 2017 VA spine examination and opinion weighs heavily against the service connection claim for a neck disorder. With regard to lay evidence of a nexus of a current neck disorder to the Veteran's active service, the lay evidence analysis is the exact same as the analysis for the low back above. The Veteran's lay assertions are acknowledged by the Board, but are outweighed by the clinical evidence of record discussed above. Accordingly, the preponderance of the evidence is against the Veteran's service connection claim for a neck disorder. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. (CONTINUED ON NEXT PAGE) ORDER Subject to the provisions governing the award of monetary benefits, service connection for bilateral hearing loss disability is granted. Subject to the provisions governing the award of monetary benefits, service connection for tinnitus is granted. Subject to the provisions governing the award of monetary benefits, service connection for a headache disorder as a residual of a TBI is granted. Service connection for a right ankle disorder is denied. Service connection for a low back disorder is denied. Service connection for an upper back (neck) disorder is denied. ____________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs