Citation Nr: 1804323 Decision Date: 01/22/18 Archive Date: 01/31/18 DOCKET NO. 10-35 907 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a left knee disorder. 2. Entitlement to service connection for a right knee disorder. 3. Entitlement to service connection for residuals of right 2nd and 4th toe fractures. 4. Entitlement to service connection for residuals of a traumatic brain injury (TBI) with post-traumatic headaches. 5. Entitlement to service connection for urinary tract infection. 6. Entitlement to service connection for a gastrointestinal disorder. 7. Entitlement to service connection for mucous colitis and dysentery, bacillary. 8. Entitlement to service connection for hepatitis and hepatic steatis. 9. Entitlement to service connection for a liver disorder, including cirrhosis. 10. Entitlement to service connection for anemia. 11. Entitlement to service connection for tinnitus. 12. Entitlement to service connection for a psychiatric disorder, to include posttraumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant and spouse ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran served on active duty from January 1983 to February 2003. These matters are before the Board of Veterans' Appeals (Board) on appeal from August 2009, December 2009, and June 2013 rating decisions by the Roanoke, Virginia, Department of Veterans Affairs (VA) Regional Office (RO). In July and December 2012, informal conferences were held before a Decision Review Officer (DRO) at the RO; summaries are associated with the Veteran's record. In December 2013, a hearing was held before a DRO at the RO; a transcript of the hearing is associated with the Veteran's record. In January 2014 and December 2016, the case was remanded to provide the Veteran a hearing before the Board. Before the November 2016 Board hearing, the Veteran requested to have his hearing before the Board cancelled. Thus, the hearing request is deemed withdrawn. 38 C.F.R. § 20.704 (2017). The issue of entitlement to service connection for a psychiatric disorder, to include PTSD, and the claim for service connection for tinnitus, are addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The weight of the evidence is against finding that a current left knee disability was incurred in service or is otherwise related to service, and arthritis did not manifest to a compensable degree within one year of discharge. 2. The weight of the competent medical evidence is against a finding of a current right knee disability. 3. The weight of the evidence is against finding that the Veteran's TBI with post-traumatic headaches was incurred in service or is otherwise related to service. 4. The weight of the competent medical evidence is against a finding of a current disability associated with residuals of right 2nd and 4th toe fractures. 5. The weight of the evidence is against finding that a disability associated with urinary tract infections was incurred in service or is otherwise related to service. 6. The weight of the evidence is against finding that a gastrointestinal disability was incurred in service or is otherwise related to service. 7. The weight of the evidence is against a finding that the Veteran's current mucous colitis and dysentery, bacillary, was incurred in or is otherwise related to service. 8. The weight of the evidence is against a finding that the Veteran's current hepatitis was incurred in or is otherwise related to service. 9. The weight of the evidence is against a finding that the Veteran's current liver disorder was incurred in or is otherwise related to service. 10. The weight of the evidence is against a finding that the Veteran's current anemia was incurred in or is otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.303, 307, 3.309 (2017). 2. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2012); 38 C.F.R. § 3.303 (2017). 3. The criteria for service connection for residuals of right 2nd and 4th toe fractures have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2012); 38 C.F.R. § 3.303 (2017). 4. The criteria for service connection for TBI with post-traumatic headaches have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5107 (West 2012); 38 C.F.R. §§ 3.303, 307, 3.309 (2017). 5. The criteria for service connection for urinary tract infections have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2012); 38 C.F.R. § 3.303 (2017). 6. The criteria for service connection for a gastrointestinal disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2012); 38 C.F.R. § 3.303 (2017). 7. The criteria for service connection for mucous colitis and dysentery, bacillary, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2012); 38 C.F.R. § 3.303 (2017). 8. The criteria for service connection for hepatitis have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2012); 38 C.F.R. § 3.303 (2017). 9. The criteria for service connection for liver disease, to include cirrhosis, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2012); 38 C.F.R. § 3.303 (2017). 10. The criteria for service connection for anemia have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2012); 38 C.F.R. § 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist 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). Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Shedden, 381 F.3d at 1167; Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain chronic diseases, such as arthritis, organic neurological disorders, including tinnitus, and brain hemorrhage, brain thrombosis, and tumors of the brain, may be presumed to have been incurred in service by showing that the disease manifested itself to a degree of 10 percent or more within one year (three years for active tuberculous disease and Hansen's disease; seven years for multiple sclerosis) from the date of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Such a chronic disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). The term "chronic disease" refers to those diseases listed under section 1101(3) of the statute and section 3.309(a) of VA regulations. 38 U.S.C. § 1101(3); 38 C.F.R. § 3.309 (a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). For such diseases, the second and third elements of service connection may be established by demonstrating (1) that a condition was "noted" during service; (2) post-service continuity of symptoms; and (3) medical or, in certain circumstances, lay evidence of a link between the present disability and the continuity of symptoms. 38 C.F.R. § 3.303(b); see Walker, 708 F.3d at 1340. If a chronic condition is noted during service or during the presumptive period, but the chronic condition is not "shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned," i.e., "when the fact of chronicity in service is not adequately supported," then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Walker at 1336; 38 C.F.R. § 3.303(b). With respect to chronic diseases under 38 C.F.R. § 3.309(a), continuity of symptomatology alone can be sufficient to establish service connection. Walker. Under section 3.310(a), service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert, 1 Vet. App. at 54. Left knee disorder The service treatment records show that in 1985 the Veteran was treated for bilateral shin splints. In February 1989 he was treated for left knee bursitis, which was subsequently noted to have resolved with treatment. A September 1994 clinical treatment note recorded patellofemoral pain syndrome with patellar tendinitis. On separation from service the Veteran denied a history of knee trouble and his lower extremities were clinically evaluated as normal. After service, treatment records noted complaints of left knee pain. 2003 left knee x-rays revealed no abnormalities. In December 2007 the Veteran fractured his left leg when he was struck by a motor vehicle. He required surgical repair. January 2008 x-rays of the left knee showed postoperative changes for comminuted fracture of the proximal tibia. Thus, the evidence does not reflect a chronic left knee disability since service or within one year following discharge from service. Therefore, to establish service connection, the evidence must show that the Veteran's current left knee disorder is causally related to service. On VA examination in September 2009 the Veteran reported a history of onset of knee symptoms in 1987, with surgery after MVA 2007. The examiner opined that the Veteran's claimed left knee disorder was less likely than not due to service because examination of the left knee revealed that the only current disorder found to be present was status post-left knee surgery, which was related to the December 2007 MVA. The examiner's findings were based on a review of the evidence, including the service treatment records and examination reports, which did not substantiate a finding that a chronic left knee disability was incurred in service. The examiner considered the complete record and the Veteran's contentions, and provided an explanation as to why the evidence does not support his contentions. Additionally, the VA examiner provided reasoning that is supported by the record. The Board finds this opinion is highly probative. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 -04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Finally, the opinion is consistent with other evidence of record and is of significant probative value. To the extent the Veteran believes that his current left knee disorder is related to service, to include any injuries incurred therein, as a lay person, the Veteran does not have the specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In this regard, the diagnosis and/or etiology of degenerative joint disease require medical testing and expertise to determine. Moreover, whether the symptoms the Veteran experienced in service or following service are in any way related to his current left knee disorder, is a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the Veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's own opinion regarding the etiology of the left knee disorder, is not a competent medical opinion. The only probative evidence of record as to nexus is the reasoned conclusion of the VA examiner who has objectively found that a left knee disorder is not a result of service, to include any injuries incurred therein. Nieves-Rodriguez, 22 Vet. App. at 304. In summary, there is no competent evidence of arthritis of the left knee in service or within one year following discharge from service. Thus, the provisions regarding continuity of symptomatology are not applicable. See Walker, 708 F.3d at 1340 (holding that only conditions listed as chronic diseases in 38 C.F.R. § 3.309(a) may be considered for service connection under 38 C.F.R. § 3.303(b) (2017). Moreover, the most probative and persuasive evidence is against a finding that his current left knee disorder is related to service. Accordingly, the preponderance of the evidence is against the claim, and service connection is denied. As the preponderance of the evidence is against service connection for a left knee disorder, the claim must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; see also Ortiz v. Principi, 274 F.3d 1361, 1366 (Fed. Cir. 2001). Right knee disorder and residuals of right 2nd and 4th toe fractures The Veteran claims that he is entitled to service connection for a right knee disorder and residuals of right 2nd and 4th toe fractures. The service treatment records show that in April 1985 he was seen for bilateral shin splints. He was treated for a fracture of the 2nd and 4th right toes in October and November 1987. The remainder of the service treatment records contain no complaints, history or findings consistent with a chronic right knee or right toe disability. On VA examination in September 2009 the Veteran reported injuring his right toe in 1988 when he walked into a dresser. He was diagnosed with status post right toe fracture, healed uneventfully without complication or functional deficit. He denied any pain, weakness, stiffness, swelling or fatigue. He denied a history of infections, hospitalizations, treatment or surgery for the condition. The Veteran denied any functional impairment from this condition. X-rays of the right foot were within normal limits. Sensory function and reflexes were normal. The examiner determined that the condition resolved and no current diagnosable disability was found on examination. On VA examination in September 2012, the Veteran complained of discomfort in the right knee since 1990. On examination, the Veteran exhibited full range of motion of the right knee with no objective evidence of pain. There was no tenderness or weakness. The was no joint instability. There was no evidence of patellar subluxation or dislocation. X-rays revealed no abnormalities. The examiner determined that there was no right knee pathology to support a diagnosis. Imaging studies in July 2013 were suggestive of medial subluxation of the right patella. Significantly, the Veteran's current medical chart did not document a chronic right knee or right toe disability. Given the above, the weight of the evidence is against a finding that the Veteran has been diagnosed with a specific diagnosis for right knee or right toe disorder, during the appeal period. McClain v. Nicholson, 21 Vet. App. 319 (2007). While the VA examiners acknowledged the Veteran's complaints of discomfort, neither a right knee nor right toe disability was diagnosed. Likewise, no chronic disability is reflected in the treatment records. In the absence of proof of a current disability, there can be no valid claim. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer, 3 Vet. App. at 225. In the absence of any competent evidence of a right knee or right toe disability, the Board must conclude the Veteran does not currently suffer from such disability. Without competent evidence of a diagnosis, the Board must deny the Veteran's claims. See Degmetich v. Brown, 104 F.3d 1328, 1333 (1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). The Board finds that the VA examiners' opinions are the most probative of record as the opinions were based on a review of the evidence and clear rationales are provided in support of the conclusions. See Boggs v. West, 11 Vet. App. 334 (1998). Given the depth of the examination reports and opinions, and the fact that the opinions were based on a review of the applicable record, the Board finds such opinions are probative and material to the Veteran's claims for service connection for right knee or right toe disorders. See Owens v. Brown, 7 Vet. App. 429 (1995). Based on the examiners' opinions, the Board cannot reach a finding that the Veteran has a current right knee or right toe disability that is related to service. There are no contrary opinions of record. Although the Board has given consideration to the lay evidence from the Veteran, he does not have the requisite medical expertise to find that his current conditions are due to service. His opinion in this regard is not competent, given the complexity of the medical questions involved. In light of the Veteran's assertions, medical opinions were sought based on a review of the entire medical record which were negative. The medical evidence and opinions outweigh the lay contentions of the Veteran. Jandreau, 492 F.3d 1372. In summary, the Veteran has not been diagnosed with a right knee or right toe disability for which service connection can be considered. Accordingly, the preponderance of the evidence is against the claims and the claims for service connection for a right knee or right toe disability must be denied. See 38 U.S.C. § 5107 (b) (West 2012); Ortiz, supra; Gilbert, supra. Residuals of a traumatic brain injury with post-traumatic headaches The Veteran contends that he currently suffers from traumatic brain injury due to an in-service injury incurred in May 1989 that resulted in a fracture to the left mandible requiring surgical repair. The Board notes that service connection has been established for postoperative fractured left mandible. The service treatment records show that in May 1988 the Veteran was treated for injuries incurred after being hit in the forehead with another soldier's helmet while playing soccer. He reported complaints of headaches, occasional blurred vision, neck pain and neck stiffness, but he denied any loss of consciousness. X rays of the cervical spine were within normal limits and he was found to be neurologically intact. The diagnosis was closed head trauma with a normal examination. He was advised to take Tylenol as needed for your headaches and to rest before returning for evaluation the next morning. On objective clinical evaluation the next morning, he was noted to be neurologically intact. He was given Motrin for continued neck pain and headaches. He was placed on light duty status for four days. The diagnosis of closed head trauma was continued and he was advised to return for follow up evaluation if he felt no improvement. In May 1989 the Veteran sustained a mandible fracture. At that time he denied any loss of consciousness. On separation from service in December 2002 he denied a history of frequent or severe headaches, a head injury, memory loss or amnesia, and objective clinical evaluation revealed no neurological abnormalities. After service, in December 2007 the Veteran was injured when he was struck by a motor vehicle while he was walking. Reportedly, upon being struck he hit the windshield and rolled over the car. He lost consciousness at the scene and amnesia was noted. The Veteran had a prolonged hospital course secondary to this closed head injury. Limited cognitive function was noted. In connection with his claim for Social Security Administration (SSA) benefits, the Veteran reported cognitive impairment having onset in December 2007 when he was a pedestrian struck by a motor vehicle. SSA contain a psychological evaluation report dated May 2008 that noted the Veteran's report of neurocognitive difficulties having onset approximately four months earlier after he was injured in a motor vehicle accident. The clinician noted that medical records showed that the Veteran sustained traumatic closed head injury and fractured left leg in December 2007 when he was struck by a motor vehicle as a pedestrian. The Veteran hit the windshield and rolled over the car. There was an observed loss of consciousness at the site of the injury. He was medically transported to hospital where diagnostic imaging revealed a left frontoparietal intraparenchymal contusion and right posterior parietal hematoma, consistent with a coup-contra-coup pattern of brain injury. His Glasgow Coma Scale rating upon entry to the Sentara trauma was reported to have been a 12. Neurosurgery was consulted and recommended nonoperative treatment of the hematoma. He also suffered multiple facial fractures as well as extensive left tibial/fibial fractures. He initially required ventilation treatment at the intensive care unit. He was diagnosed with cognitive disorder, not otherwise specified (NOS), secondary to TBI, headaches and chronic leg and knee pain. On VA examination in May 2009, the Veteran reported being diagnosed with closed head trauma in 1989 and again in 2007. Following the 2007 injury he was hospitalized for four months. The Veteran complained of retrograde amnesia, which he claimed had onset in 1989 when he was assaulted. The Veteran stated that at that time he lost consciousness for less than 30 minutes. He also reported headaches described as throbbing pain in temples. Examination showed mild memory loss and mild functional impairment. The subjective factors were memory loss. The objective factors were medication documentation. The examiner noted that Veteran experienced a focal injury TBI, which was classified as moderate in severity. The condition had stabilized and the Veteran currently suffered from post-concussion syndrome post concussive with anxiety and related headaches. The Veteran had been unable to work since his accident in 2007. On VA examination in August 2009, the Veteran reported having been severely beaten by two men in Hawaii in 1989. Reportedly, he was hospitalized for a period of several weeks for medical care. The Veteran also sustained a second head injury in December 2007 when he was struck by a drunk driver in a-severe accident. He was hospitalized for two months and underwent rehabilitation for two months. The examiner diagnosed amnestic and cognitive disorders, and opined that the Veteran did not develop any type of amnestic or cognitive disorder during his tenure in service. Additionally, at the time of his discharge from active duty in 2002 the Veteran did not suffer from any cognitive or amnestic disorder. Thus the Veteran's current amnestic disorder was clearly the result of incidents which occurred subsequent to his discharge from service in December 2007. In September 2009 and independent medical opinion was obtained. The physician reviewed the evidence showing that the Veteran was injured in May 1988 when he was struck on the forehead by a fellow marine while playing soccer during recreational physical therapy. It was important to note that there was no sustained memory dysfunction noted at that time. The following day a physician diagnosed closed head trauma. No impairment of cognition was noted. The Veteran reported neck pain, headaches and transitory mild blurred vision. Approximately a year later in May 1989 the Veteran was treated for a fractured left mandible with multiple lacerations which were sutured. There was no loss of consciousness. The incident occurred after an altercation with two other men. It was noted that the Veteran was inebriated and intoxicated at that time. Again, no cognitive changes were noted. On separation from service in December 2002 the Veteran denied having headaches, head injury, amnesia, or memory loss. No neurologic deficit was noted. In December 2007 the Veteran was admitted to the hospital due to head injury with intoxication after he was struck by a motor vehicle. He was discharged in February 2008. Following a review of the claims file, the physician opined that the Veteran's current TBI with post traumatic headaches was proximately due to the December 2007 closed head trauma as there was no evidence of chronic headaches in 2002 and his current symptoms were initially noted following the December 2007 injury. The Veteran's service connection claim must be denied in this case. While the Veteran complains of headaches and cognitive problems, and while he has been diagnosed with residuals of TBI, the evidence does not establish that any such current disorder is due to his in-service injuries or to his service in any other way. The most probative evidence on the question of whether any symptoms of TBI with headaches are related to service and, specifically, to the Veteran's May 1988 and 1989 injuries, are the medical opinions of the VA examiner in August 2009, and the independent medical opinion in September 2009, reflecting that the Veteran's claimed disorder is not related to his in-service injuries, but rather to his TBI in December 2007. The VA examiner and independent medical examiner noted that symptoms currently reported, including headaches and cognitive impairment, were initially reported following the December 2007 injury. In contrast, following the in-service injuries in 1988 and 1989, although the Veteran complained and was treated for headaches, these appeared to have resolved with treatment and the records failed to document complaints of memory problems or other cognitive issues currently reported. Additionally, when examined in service he was found to be neurologically intact on discharge from active duty in 2002 the Veteran denied having headaches, head injury, amnesia, or memory loss, and no neurologic deficit was noted. The Board finds these opinions to be highly probative. Each was given by an examiner with appropriate expertise who based his opinion on a review of the entire record, including examination and interview of the Veteran, considering the Veteran's lay account of the onset of his claimed disorders. Also, each provided clear and plausible rationale for the opinion rendered, the bases of which are consistent with the evidence of record. In this regard, despite the Veteran's early complaints of headaches in 1988, which did not continue throughout service, and his December 2002 report of medical history and examination, which failed to document any of the Veteran's current symptoms. Furthermore, treatment records following the May 1989 injury and post-service discharge, reflect no complaints of or treatment for any chronic or continuing headache or cognitive impairment, despite reflecting treatment for numerous complaints and medical conditions. The Veteran began complaining of repeated or continuing headaches and memory and concentration problems after the December 2007 MVA resulting in loss of consciousness, imaging studies consistent with TBI, and treatment in an intensive care unit with subsequent impatient treatment and physical therapy. This is also consistent with the May 2008 SSA psychological evaluation report and the Veteran's reported history in connection with his claim for SSA benefits. The Board acknowledges the September 2009 opinion from the independent medical examiner that the Veteran's amnestic disorder likely started in service and had continued to the present time. However, no rationale was provided for this finding and later statements by the same examiner reach the opposite conclusion, attributing the amnestic disorder to the post-service 2007 accident. Thus, the seemingly favorable opinion offered by that independent medical examiner is outweighed by the record as a whole, to include his later findings. Finally, the Board acknowledges the assertions and statements of the Veteran and his spouse that he has suffered from and been treated for headaches and cognitive problems since the May 1988 and 1989 in-service injuries. While lay persons are competent to provide opinions on some medical issues, the issue of whether the Veteran's current residual symptoms of TBI are due to service head injuries in service, as opposed to the 2007 TBI, falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Additionally, the Board does not finds such assertions to be credible in light of the extensive service and post-service medical record reflecting the contrary, including multiple statements given by the Veteran himself, as discussed at length above. In this regard, as no chronic disease was shown within one year of service, the presumptive service connection provisions of 38 C.F.R. §§ 3.307 and 3.309(a) regarding chronic diseases are not applicable. Therefore, the evidence weighs against a finding that current residuals of TBI, including headaches, were the result of an in-service injury or are related to service in any other way. Accordingly, service connection for TBI with post-traumatic headaches must be denied. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); Gilbert, 1 Vet. App. at 53-56. Gastrointestinal disorder, urinary tract infection, and mucous colitis and dysentery, bacillary, The Veteran claims entitlement to service connection for a gastrointestinal disorder, urinary tract infection, and mucous colitis and dysentery, bacillary. The service treatment records show that October 1991 he was treated for gastroenteritis. In April 1998 he was seen for abdominal pain and vomiting. A study revealed no abnormalities. The remainder of the service treatment records contain no complaints, history or findings of gastroenteritis, urinary tract infections, or mucous colitis and dysentery, bacillary. In February 2000 the Veteran was treated for a urinary tract infection. On separation from service in December 2002 the Veteran denied a medical history of frequent indigestion, stomach trouble, and intestinal trouble. After service, the Veteran was seen for gastrointestinal problems and colitis in 2006. He was also treated for a urinary tract infection in 2008. On VA examination in May 2013, the examiner noted a history of irritable bowel syndrome and intestinal neoplasm diagnosed in 2011. The Veteran reported a history of loose bowel since 1995. He used over the counter medication to treat his symptoms. He denied weight loss, nausea or vomiting. After retirement in 2004 he sought treatment for abdominal pain and was told he had pancreatitis and gastritis. He was treated with medication. In 2006 he started having more bowel movements with abdominal cramps. Currently he continued to experience abdominal cramps, bowel movements with loose stools daily, diarrhea, abdominal distention, weight loss and anemia. Following a review of the claims file and an examination of the Veteran, the examiner opined that the Veteran's gastrointestinal condition, including mucous colitis and dysentery bacillary, were less likely as not incurred in or caused by the claimed in-service injury, event, or illness. Concerning the claimed gastrointestinal problems and mucous colitis and dysentery bacillary, the examiner explained that there was no evidence to support a diagnosis of ulcerative colitis in endoscopy 2006 and 2010. Also, gastroenteritis in October 1991 was most likely viral and resolved without follow up or recurrence since 1991. This favored a transient problem. Ulcerative colitis was a chronic and much more severe condition that affected the colon alone, with no stomach involvement, which was not noted in service. Concerning the Veteran's claimed condition of urinary tract infection, the examiner noted that on examination the Veteran denied any history of urine retention. He complained of urinary tract infection that was treated by a urologist in 2010 and since then there was no recurrence. There was no history of perineal pain after sex. Review of the claims file showed no evidence to supports urinary tract infection or urine retention. A urologist diagnosed prostatitis in 2010 and had CT scan of the pelvis which was consistent with prostatitis. Following a review of the claims file and an examination of the Veteran, the examiner opined that the Veteran's claimed condition of urinary tract infection, was less likely as not incurred in or caused by the claimed in-service injury, event, or illness. The Board finds that the VA examiner's medical opinions to be highly probative. The VA examiner's opinions were based on a thorough review of the claims file, including the service treatment records and examination of the Veteran, and the opinions are consistent with other evidence of record. Moreover, the examiner provided adequate rationale for the opinions provided and cited to the medical evidence in support of the opinions. Accordingly, the VA examiner's opinions are entitled to great probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. To the extent the Veteran believes that he currently suffers from a gastrointestinal disorder, urinary tract infection, and mucous colitis and dysentery, bacillary, that are related to service, as a lay person, the Veteran does not have the specialized training sufficient to render such an opinion. See Jandreau, 492 F.3d at 1377, n. 4. Thus, the Veteran's own opinion regarding the etiology of the claimed gastrointestinal disorder, urinary tract infection, and mucous colitis and dysentery, bacillary, is not a competent medical opinion. Moreover, the most probative and persuasive evidence is against a finding that his claimed gastrointestinal disorder, urinary tract infection, and mucous colitis and dysentery, bacillary, are related to service. Significantly, there is no competent medical evidence that supports the claims. Accordingly, the preponderance of the evidence is against the claims, and service connection is denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims for service connection for a gastrointestinal disorder, urinary tract infection, and mucous colitis and dysentery, bacillary. As such, that doctrine is not applicable in the instant appeal, and the claims must be denied. See 38 U.S.C. § 5107 (b) (West 2012); Ortiz, supra; Gilbert, supra. Hepatitis and hepatic steatis, liver disease and anemia The Veteran contends that he is entitled to service connection for hepatitis and hepatic steatis, as well as liver disease, including cirrhosis. He also claims entitlement to service connection for anemia. He has asserted that he became symptomatic for these conditions during service. The service treatment records contain no complaints, history or findings consistent with hepatitis, cirrhosis of the liver or anemia. After service, treatment record in 2006 documented hepatic steatosis and anemia. Imaging studies in June 2006 showed diffuse low attenuation consistent with hepatic steatosis. The Veteran's current medical chart includes a history of autoimmune hepatitis and fatty liver with elevated liver enzymes, as well as anemia. Here, there is no competent and credible evidence of a nexus between the Veteran's current hepatitis, liver disease or anemia, and service. The only evidence of record in support of such a nexus is the Veteran's lay evidence, and to the extent that they are being offered to establish a nexus, such evidence fails because this determination is a complex medical matter beyond the realm of common knowledge of a layperson. The Veteran does not have the requisite medical knowledge, training, or experience to be able to render a competent medical opinion regarding the cause of the medically complex disorder of hepatitis, liver disease or anemia. See Jandreau, supra; Kahana, supra. Hepatitis, liver disease and anemia, are medically complex disease processes because of their multiple possible etiologies, require specialized testing to diagnose, and manifest symptomatology that may overlap with other disorders. Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis). Further, the etiology of the Veteran's current hepatitis, liver disease or anemia, is a complex medical etiological question involving internal and unseen system processes unobservable by the Veteran. Accordingly, the Veteran's assertions as to a relationship between his hepatitis, liver disease and anemia, and service are of little probative value. A VA examination or medical opinion regarding the etiology of his currently diagnosed hepatitis, liver disease or anemia, was not indicated as there is no suggestion that the Veteran's current disabilities may be associated with service. Again, there is no competent evidence of hepatitis, liver disease or anemia, in service or within one year following discharge from service. Moreover, there is no competent and probative evidence to show that the Veteran had hepatitis, liver disease or anemia, during or contemporaneous with service and no competent and probative evidence that his current disorders are related to his service. Given the foregoing, the Board finds that the preponderance of the evidence is against the claims for service connection for hepatitis, liver disease or anemia, and that the claims must be denied. The Board has considered the applicability of "benefit of the doubt" doctrine, however, the record does not demonstrate an approximate balance of positive and negative evidence as to warrant the resolution of these matters on that basis. See 38 U.S.C. § 5107 (b) (West 2012); Ortiz, supra; Gilbert, supra. ORDER Service connection for a left knee disorder is denied. Service connection for a right knee disorder is denied. Service connection for residuals of right 2nd and 4th toe fractures is denied. Service connection for traumatic brain injury with post-traumatic headaches is denied. Service connection for urinary tract infection is denied. Service connection for a gastrointestinal disorder is denied. Service connection for mucous colitis and dysentery, bacillary, is denied. Service connection for hepatitis is denied. Service connection for liver disease, to include cirrhosis, is denied. Service connection for anemia is denied. REMAND The Veteran contends that he currently suffers from a psychiatric disorder that had onset in service. The service treatment records document treatment for suicidal ideation, along with diagnoses of immaturity, adjustment disorder and depression. After service, in 2006, prior to his December 2007 TBI, the Veteran was seen for anxiety problems. In January 2007 he was hospitalized for suicidal ideation. He was diagnosed with major depressive disorder, generalized anxiety disorder, alcohol abuse and obsessive compulsive disorder. The Veteran has been afforded multiple examinations throughout the appeal and medical opinions have been obtained regarding the etiology of the Veteran's cognitive complaints, including amnestic disorder. However, it is unclear whether other mental health disorders are present and if so, whether any such disorder is related to the Veteran's treatment for depression in service. Significantly, the examination reports failed to address the Veteran's history of treatment for depression in service, as well as psychiatric treatment prior to the December 2007 TBI. Based on the foregoing, the Board finds that a remand is needed for a VA medical examination and opinion report that addresses the Veteran's history of mental health treatment, both in service and post-service discharge. Concerning the claim for service connection for tinnitus, the Veteran claims that he developed tinnitus due to the service-connected mandible fracture. Specifically, at his December 2013 hearing before a DRO, the Veteran reported ringing in his ears, having onset a few months earlier, which he attributed to the mandible fracture. As noted, service connection has been established for postoperative fractured left mandible. The Veteran is competent to report ringing in his ears. For VA purposes, tinnitus is the type of disorder associated with symptoms capable of lay observation. See Charles v. Principi, 16 Vet. App. 370 (2002). However, as a lay person the Veteran is not competent to associate tinnitus to the service-connected left mandible fracture. Specifically, whether an injury to the left mandible may have caused pathology, such as to the inner ear, resulting in the development of tinnitus is a determination that is too complex to be made based on lay observation alone. See Jandreau, 492 F.3d at 1377 (Fed. Cir. 2007). As there is evidence of an in-service injury and the Veteran is competent to report that he has had tinnitus, a medical opinion is necessary to determine if there is a relationship between the in-service fractured left mandible and his current tinnitus. Finally, relevant ongoing medical records should also be obtained. Accordingly, the case is REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of all medical care providers, both VA and private, who have recently treated him for mental health problems and tinnitus. After securing any necessary releases, request any identified records that are not duplicates of those already contained in the claims file. If any requested records are not available, the Veteran and his representative, if any, should be notified of such. 2. Request updated relevant VA treatment records. If any requested records are not available, the Veteran should be notified of such. 3. Schedule the Veteran for a VA psychiatric disability examination to determine whether any current psychiatric disorder is related to military service. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. a. Following review of the claims file and examination of the Veteran, the examiner should identify all psychiatric disorders, to include PTSD. The examiner should specifically determine if the Veteran meets the diagnostic criteria for PTSD. If the Veteran does not meet the criteria for PTSD, the examiner should explicitly discuss which criteria for diagnosis are missing (under either DSM-IV or DSM-V criteria). b. If PTSD is diagnosed, the examiner should opine whether it is at least as likely as not (a 50 percent or greater probability) PTSD began in or is otherwise related to military service. c. For each psychiatric disability diagnosed, other than PTSD, the examiner should provide an opinion regarding whether each disorder at least as likely as not (a 50 percent or greater probability) began in or is otherwise related to military service. All opinions must be supported by a clear rationale, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The examiner should also address the service treatment records that document treatment for suicidal ideation, along with diagnoses of immaturity, adjustment disorder and depression, as well as mental health treatment January 2007. 4. Schedule the Veteran for a VA examination to determine whether tinnitus is related to service or a service-connected disability. The claims file must be made available to and be reviewed by the examiner in conjunction with the examination. The examiner should state whether it at least as likely as not (50 percent probability or greater) that tinnitus is related to any aspect of the Veteran's active service, to include the May 1989 fracture to the left mandible. Please explain why or why not. The examiner is advised that the Veteran is competent to report his symptoms and history. In formulating his or her opinion, the examiner should specifically address the Veteran's December 2013 hearing testimony wherein he reported onset of tinnitus a few months earlier. 5. Finally, readjudicate the appeal. If any benefit sought on appeal remains denied, furnish the Veteran and his representative a supplemental statement of the case and provide an appropriate period of time to respond. The case should then be returned to the Board for further appellate review, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (West 2014). ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs