Citation Nr: 18143350 Decision Date: 10/18/18 Archive Date: 10/18/18 DOCKET NO. 16-02 332 DATE: October 18, 2018 ORDER Service connection for a back disability is granted. Service connection for bilateral hearing loss is denied. Service connection for a bilateral hand disability is denied. Service connection for a neck disability is denied. Service connection for a bilateral knee disability is denied. Service connection for a bilateral ankle disability is denied. Service connection for sleep apnea is denied. REMANDED Entitlement to an initial disability rating in excess of 10 percent for the right shoulder strain is remanded. FINDINGS OF FACT 1. The Veteran’s mid- and low-back disabilities began during active service. 2. The Veteran does not have a current bilateral hearing loss disability. 3. Symptoms of bilateral hand, neck, bilateral knee, and bilateral ankle disabilities and sleep apnea were not continuous or recurrent in service or since service separation; and there is no medical nexus between the current bilateral hand, neck, bilateral knee, or bilateral ankle disabilities or sleep apnea and active service. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for a back disability have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 2. The criteria for service connection for a bilateral hearing loss disability have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.385. 3. The criteria for service connection for a bilateral hand disability have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 4. The criteria for service connection for a neck disability have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 5. The criteria for service connection for a bilateral knee disability have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 6. The criteria for service connection for a bilateral ankle disability have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 7. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant in this case, had active service from October 1986 to June 2007. This matter comes before the Board of Veterans’ Appeals (BVA or Board) from a June 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. 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). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. The conditions at issue are not any of the “chronic diseases” listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) (requiring continuity of a condition after service if chronicity is not found in service) does not apply to this case. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also 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). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The United States Court of Appeals for Veterans Claims (Court) has held that “Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim.” Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). 1. Service connection for a back disability The Veteran contends that he incurred back, neck, bilateral ankle, bilateral hand, and bilateral knee disabilities as a result of more than 20 years in active service as an aircraft mechanic. His job duties were physically strenuous, and involved bending, crawling, lifting, etc. For the reasons discussed below, resolving reasonable doubt in the Veteran’s favor, the Board finds that the current back disability was incurred during active service. Service treatment records show multiple complaints, treatment, and diagnoses of a back problem. In January 1993, the Veteran reported pain in his mid-back of three days’ duration that increased with movement such as bending. He denied any specific trauma. On physical examination, there was mild tenderness of the paraspinal muscles at T11-12 and over left lateral dorsi. He was diagnosed with a muscle strain. At an April 1995 periodic medical examination, the Veteran checked “yes” next to “recurrent back pain” on his Report of Medical History. The clinician noted minor lower back pain occasionally. At a February 1996 annual examination, the Veteran again reported recurrent back pain. Although clinical evaluation of the spine was marked as normal, the clinician noted that the Veteran had a recurrent low back problem but was not currently on profile. In September 1997, the Veteran reported chronic low back pain for 11 years, with more recent mid-back pain. The lumbar spine was tender to palpation at L5-S1. In May 1998, the Veteran complained of mid-thoracic back pain. He stated that he had experienced this pain many times before, and that usually a doctor “popped it back in.” There was mild tenderness to the thoracic lumbar paraspinal muscles. The diagnosis was thoracic back pain. The clinician recommended a trial of medication, and if there was no improvement, physical therapy. In July 1998, the Veteran requested a records review for deployment. The clinician noted a history of thoracic back pain, but concluded that he was qualified for deployment. In February 1999, an Addendum to Medical Record indicates that the Veteran had a muscle strain of the mid-back in January 1993, which was treated with Indocin with poor results. In addition, he had a thoracic strain in October 1997, which was treated with manipulation, Norgesic, and physical therapy with poor results. In April 2000, the Veteran reported that he had recently experienced mid-back pain. In July 2001, the Veteran sought treatment for low back pain that began on April 6, 2001. On that date, he was moving heavy objects the night prior and had sudden onset of low back pain. On current examination, he had pain on extension. The diagnosis was low back pain with sciatica, and he was given medication. In January 2003, the Veteran was placed on physical profile for a lumbar back sprain. A physical therapy note dated in the same month indicates a history of acute low back pain for one week associated with left lower extremity pain to the knee, as well as a history of low back pain one year prior from a lifting injury. A March 2003 service treatment record indicated that the Veteran had back pain, that he was on profile and was treated with steroids and physical therapy. A May 2003 treatment note indicates that the Veteran had a history of low back pain and was still having problems. He had been on temporary profile from January to February 2003 for back pain and had not been back to the clinic since then. He was treated with physical therapy. The clinician told him to talk to his doctor about profile restrictions. In September 2003, the Veteran sought treatment for a recurrence of lower back pain for one week. It was noted that he had a history of back pain in 2001 due to heavy lifting, and at that time, he had three weeks of symptoms before improvement. He reported that the current pain radiated into his left leg, and he had limited range of motion. The diagnosis was lumbago/sprain, and he was given medication and placed on physical profile. In February 2007, a Report of Medical Assessment indicates that the Veteran intended to seek VA disability benefits for his back problem. Following separation from service, in February 2010, private chiropractic treatment notes indicate that the Veteran reported back pain that began “years ago.” Currently, he stated his upper and lower back pain was constant. No trauma was noted. In an October 2014 letter, the Veteran stated he sought treatment for severe low back pain in 2010 from a chiropractor for six months, and that it helped, but cost too much to continue. The Veteran was afforded a VA examination in May 2015. The examiner diagnosed a chronic lumbar and thoracic strain, first diagnosed in the mid-1990s. The Veteran stated that he could not recall any specific injury, but stated that in the mid-1990s, after multiple jumps, bending, and straining at work, he required multiple chiropractic visits. Currently, he stated that his upper and lower back hurt constantly, and that he took Ibuprofen as needed. The VA examiner opined that the back condition is the result of mechanical wear and tear caused by job duties, but no specific injury, illness, or event. In a June 2015 Gulf War General Medical Examination report, a VA examiner stated that the chronic lumbar and thoracic strain were diseases with clear and specific etiology and diagnoses. Research published in peer-reviewed medical journals has not established a causal relationship between these conditions and exposure events experienced by service members in southwest Asia. VA treatment records show ongoing treatment for thoracic and lumbar spine problems, including physical therapy in 2015. In sum, the medical evidence of record demonstrates consistent thoracic and lumbar spine problems since 1993, while the Veteran was in active service. While the June 2015 VA examiner stated that there was no specific injury or event that caused the mid- and lower-back problems, he stated that it was more likely due to mechanical wear and tear caused by job duties, which, combined with the documented back pain in service, tends to support the Veteran’s contentions. Resolving reasonable doubt in the Veteran’s favor, the Board finds that service connection for a back disability is warranted. 2. Service connection for bilateral hearing loss Next, the Veteran contends that years of working around aircraft in the course of performing his duties as an aircraft mechanic during active service caused a current hearing loss disability. However, as discussed below, a hearing loss disability, as defined by VA regulations, has not been demonstrated by the evidence. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater, or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, 4000 Hertz are 26 decibels or greater, or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. Also, the threshold for normal hearing is between 0 and 20 decibels, and higher threshold shows some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). The Board finds that the weight of the evidence demonstrates that the Veteran’s currently claimed bilateral hearing loss does not meet the definition of a hearing loss disability as required by 38 C.F.R. § 3.385, including during active service. A March 1986 enlistment examination report includes the results of an audiogram which revealed puretone thresholds of 5, 0, 0, 0, and 5 decibels in the right ear, and 0 decibels at all levels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. In April 1987, an audiogram demonstrated puretone thresholds of 5, 0, 0, 0, and 5 decibels in the right ear, and 5, 0, 0, 0, and 0 decibels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. In July 1987, an audiogram demonstrated puretone thresholds of 0 decibels at all levels in the right ear, and 5, 0, 5, 5, and 5 decibels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. A September 1989 physical examination report includes a Report of Medical History on which the Veteran checked “no” next to “hearing loss.” At a December 1990 medical examination for flying personnel, an audiogram revealed puretone thresholds of 0, 0, 0, 0, and 5 decibels in the right ear, and 0 decibels at all levels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. At a January 1992 Annual Flying Examination, an audiogram revealed puretone thresholds of 0, 0, 5, 0, and 10 decibels in the right ear, and 5, 0, 0, 0, and 5 decibels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. In December 1992, an audiogram revealed puretone thresholds of 0, 0, 5, 0, and 10 decibels in the right ear, and 5, 0, 0, 0, and 5 decibels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. At an April 1995 physical examination, the Veteran denied hearing loss. A February 1996 Hearing Conservation Examination report indicates that the Veteran denied having hearing loss of any kind. In February 1999, a Hearing Conservation Examination report indicates that the Veteran stated he was unsure as to whether he currently had any hearing loss. However, he denied having any difficulty hearing warning bells, sirens, telephone conversation, in noisy rooms, or normal speech. An audiogram revealed puretone thresholds of 0, -5, 5, 0, and 15 decibels in the right ear, and 10, -5, 5, 5, and 0 decibels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. In February 2003, an audiogram revealed puretone thresholds of 0, 0, 5, 0 and 0 decibels in the right ear, and 0, 0, 5, 0, and 0 decibels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. In April 2004, an audiogram revealed puretone thresholds of 5, 0, 0, 0, and 5 decibels in the right ear, and 5, 5, 0, 5, and 5 decibels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. In February 2005, an audiogram revealed puretone thresholds of 0, 0, 0, 0, and 5 decibels in the right ear, and 0, 0, 0, 5, and 5 decibels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. In May 2006, an audiogram revealed puretone thresholds of 5, 0, 0, 0, and 10 decibels in the right ear, and 0, 0, 0, 0, and 10 decibels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. Following separation from service, in April 2014, medical records from the 72nd Medical Group indicate that an audiogram was conducted, but specific results are not included in the records. The Veteran was released without limitations, and it was noted that the results did not exceed H-1 profile. The Veteran filed his claim of entitlement to service connection for bilateral hearing loss in September 2014, stating that he first noticed hearing loss in 2001. Private treatment records from January 2015 reveal that the Veteran reported hearing loss that was slowly progressive. An audiogram was conducted but the specific results were not documented in the records. The diagnosis was high frequency bilateral sensorineural hearing loss. The Veteran was instructed to use hearing protection in noisy environments and to return for annual audiograms. The Veteran was afforded a VA audiological examination in May 2015. An audiogram revealed puretone thresholds of 10, 15, 10, 15, and 20 decibels in the right ear, and 15, 10, 20, 15, and 20 decibels in the left ear at the test frequencies of 500, 1000, 2000, 3000, and 4000 Hz, respectively. Speech discrimination was 96 percent in the right ear and 100 percent in the left ear. The examiner noted that during active service, he was exposed to hazardous noise in the form of jet aircraft engine noise and loud generator noise. He was an office worker until June 2014, when was hired as an aircraft maintenance worker. The examiner did not provide a nexus opinion as the Veteran had normal hearing. In sum, there is no medical evidence of record that demonstrates a current bilateral hearing loss disability under VA regulations. Regarding the Veteran’s statements that he has a bilateral hearing loss disability, the Board recognizes that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. Sept. 14, 2009) (Board’s categorical statement that “a valid medical opinion” was required to establish nexus, and that a layperson was “not competent” to provide testimony as to nexus because she was a layperson, conflicts with Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007)). However, while the Veteran is competent to provide his lay description of hearing loss symptoms, he is not competent to determine whether his claimed hearing loss meets the definition of a hearing loss disability as defined by VA regulations. Such a finding can only be made via the appropriate audiological testing and requires specific medical knowledge and training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). Without a showing of current hearing loss disability in accordance with the provisions of 38 C.F.R. § 3.385, service connection for bilateral hearing loss must be denied. “Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability... in the absence of a proof of present disability there can be no claim.” Brammer, 3 Vet. App. at 225. The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, where the overall record fails to support a current diagnosis of the claimed disability, as is the case here, that holding would not apply. Because a current hearing loss disability has not been shown by competent evidence, the Board does not reach the additional question of the relationship of the claimed hearing loss to any loud noise exposure in service. For these reasons, the claim for service connection for bilateral hearing loss must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Service connection for bilateral hand, neck, bilateral knee, and bilateral ankle disabilities, and sleep apnea As noted above, the Veteran contends that the physical demands of his job as aircraft mechanic during active service caused his current bilateral hand, neck, bilateral knee, and bilateral ankle disabilities. He also avers that his sleep apnea began during active service. For the reasons discussed below, the Board finds that a medical nexus between the claimed disabilities and active service has not been demonstrated, and that service connection is not warranted. Service treatment records show that the Veteran suffered a laceration to the right hand in November 1989. However, the injury resolved completely within one week, as a treatment note dated November 6, 1989 indicates that the Veteran reported that his hand was “totally better,” and subsequent service treatment records are negative for any right-hand problems. He also suffered a laceration to the left hand in August 1999, and required sutures. The sutures were removed in September 1999 and he was told he could resume normal activities. There is no further mention of left hand problems, and an April 2000 Addendum to Medical Record indicates that he received no medications for the left-hand injury, that there were no complications, and that the condition was resolved. The service treatment records include an August 1999 x-ray report of the cervical spine which was negative, with no fractures, dislocations, or destructive lesions. This x-ray was performed after the Veteran fell backwards and hit his head. The treatment records surrounding this incident do not contain any reports or complaints of neck pain. At a March 2006 Post-Deployment Health Assessment following deployment to South America from April 2006 to July 2006, the Veteran stated that his health stayed the same or got better, and that he did not currently have any joint pain, or still feel tired after sleeping, nor did he experience those symptoms during deployment. He did not think he was exposed to any chemical agents other than DEET insect repellant and vehicle or truck exhaust fumes. He stated that he did not have any medical problems that developed during deployment. A February 2007 Report of Medical Assessment reveals that the Veteran stated he intended to seek VA disability benefits for knee problems. Service treatment records, however, are negative for any other reports, findings, treatment, or diagnoses of knee problems. In sum, the service treatment records show lacerations to both hands which resolved without sequelae prior to service separation, and are negative for any reports, complaints, findings, treatment, or diagnoses of neck, bilateral knee, or bilateral ankle disabilities or sleep apnea. Following separation from active service, a May 2011 private chiropractic treatment note indicates the Veteran reported neck pain, stating that he slept in an awkward position. In November 2011, the Veteran suffered a left foot navicular fracture when he was running and his foot got stuck in a hole, twisting his mid-foot. In May 2013, the Veteran reported that he snored, and he was referred for an overnight pulse oximetry. An April 2014 note from the 72nd Medical Group records indicates that the Veteran was seen for pre-employment medical clearance with no stated health concerns other than mild neck discomfort. It was noted that he worked as a truck driver. Physical examination of the musculoskeletal system was normal. He was cleared with no limitations and no need for further evaluation. In November 2014, the Veteran sought treatment for sleep trouble, stating he slept too much, was tired all the time, and snored loudly. He also reported upper back and neck pain. His wife reported witnessing apnea. He was referred for a sleep study, which was conducted in January 2015 and revealed mild obstructive sleep apnea. The notes from the sleep clinic indicate that the Veteran reported experiencing daytime sleepiness for ten years, and that he had been snoring for 20 years. The Veteran was afforded a VA examination in May 2015. First, with regard to the claimed bilateral hand disability, the examiner diagnosed a chronic bilateral hand sprain. The Veteran reported that in 1995, he began to experience aching, pain in his hands, swelling, and cramping after mechanical overuse of the joints while working on the job. With regard to the neck disability, the examiner diagnosed a chronic cervical strain, which the Veteran stated was diagnosed in the mid-1990s after he developed stiffness, pain, and aching in his neck after multiple jumps, heavy lifting, and strain at work. With regard to the knees, the examiner diagnosed a bilateral knee strain, noting that the Veteran reported heavy work loading airplane cargo during military service, with extensive amounts of climbing and jumping in and out of airplane cargo holds. He reported that he continued to work in heavily physical environments, with loading, climbing, and kneeling being regular activities for him. He reported that his knees were only mildly to moderately bothersome during service, and that he did not seek treatment for knee problems then. However, he reported that over the past two years, his knees gradually become more painful and were beginning to limit his ability to perform long workdays, and to climb in an out of semi-trucks. He also reported difficulty climbing stairs and working on his knees, which were required in his current work. Finally, with regard to the ankles, the examiner diagnosed a bilateral lateral collateral ligament strain. The Veteran reported onset of the ankle problem in the early 1990s, stating that while working as a flight line crew chief, he worked long hours on pavement, and that he sprained an ankle while walking into work (it is unclear when this injury occurred from the report). The May 2015 VA examiner opined that the claimed bilateral hand, neck, bilateral knee, and bilateral ankle disabilities were not related to any specific injury, illness, or even in service, but were likely the result of mechanical wear and tear caused by job duties, having noted that the Veteran’s post-service occupations involved heavy physical labor. With regard to the knees, the examiner further noted that service treatment records were silent for any knee problems, and that while it is certainly possible that extensive use during service could have triggered a process which progressed over time, it is more likely that continued heavy use of his knees over time, possibly combined with minor injuries after service, is a better explanation for his current bilateral knee strain. A June 2015 Gulf War General Medical Examination report listed diagnoses of bilateral ankle lateral collateral ligament strain, bilateral hand sprain, and bilateral knee strain, and the examiner stated that these conditions are diseases with clear and specific etiology and diagnoses. Further, research published in peer-reviewed medical journals has not established a causal relationship between these conditions and exposure events experienced by service members in southwest Asia. An August 2015 VA treatment note indicates the Veteran reported bilateral knee pain for years, but stated that the pain was worsening recently. The pain was worse with work, as he climbed stairs, crawled, and got in and out of airplanes in his current job. The diagnosis was bilateral knee pain and a right knee Baker’s cyst. The Veteran also reported right hand pain, so an x-ray was ordered, the results of which are not included in the records. In October 2015, the Veteran presented for bilateral knee problems. He denied any specific injury but stated it was possibly due to working on the flight line in the military for over 20 years. His symptoms began approximately more than 20 years ago and included swelling, popping, limping, grinding, pain, and decreased range of motion. The diagnosis was chondromalacia patellae of the bilateral knees. A November 2015 MRI of the left knee was normal, and an MRI of the right knee showed a possible small tear of medial meniscus and some chondromalacia. In December 2015, the Veteran underwent a right knee partial medial meniscectomy, partial lateral meniscectomy, chondroplasty of patella, and chondroplasty of medial femoral condyle. Post-operative diagnoses were medial meniscal tear, lateral meniscus tear, grade 3 chondromalacia of the patella, and grade 3 chondromalacia of medial femoral condyle. The Board has reviewed all of the lay and medical evidence of record in conjunction with the applicable laws and regulations. The Board finds that although there were lacerations to both hands and the Veteran mentioned that he intended to file a claim for a knee disability in 2007 during active service, the preponderance of the evidence demonstrates that the hand conditions resolved prior to separation, and that symptoms of the claimed disorders were not continuous or recurrent in service. As noted above, service treatment records clearly show that the lacerations to the bilateral hands resolved in a short period of time, and that the Veteran did not have any lingering complications or sequelae from those injuries. Moreover, although the Veteran expressed his intent to file a claim for disability benefits for his knees, service treatment records are completely negative for any other reports, findings, treatment, or diagnosis of a knee disability. Service treatment records are also silent as to any reports, findings, treatment, or diagnoses of the claimed neck or bilateral ankle disabilities, and as to sleep apnea. Moreover, the preponderance of the evidence demonstrates that symptoms of the claimed disorders have not been continuous or recurrent since separation from active service in June 2007. The absence of post-service complaints, findings, diagnosis, or treatment for the claimed neck and left ankle disabilities for 4 years, sleep apnea for 6 years, and right ankle, hands, and knees for 7 years after service separation is one factor that tends to weigh against a finding of continuous or recurrent symptoms of the claimed disorders after service separation. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). Additional evidence demonstrating that symptoms of the claimed disorders have not been continuous since service separation includes the treatment records demonstrating post-service injuries to the neck and left ankle. For instance, the May 2011 chiropractic treatment note shows neck pain after sleeping in an awkward position, and the November 2011 treatment notes clearly describe a post-service left ankle injury, with no history of prior ankle problems. These records tend to show that the neck and left ankle symptoms have not been continuous since service. In addition, at the May 2015 VA examination, the Veteran reported that although he experienced some knee problems during active service, his pain had increased to the point of limiting his functional abilities and requiring treatment in the past two years, supporting the VA examiner’s conclusion that the knee problem is related to post-service occupational wear and tear and providing highly probative evidence that the knee symptoms have not been continuous since active service. Further, post-service treatment records are negative for treatment for right ankle, left hand, or left knee disabilities. Although the May 2015 VA examiner rendered diagnoses with regard to the right ankle, left hand, and left knee, the absence of post-service treatment for these disabilities weighs against a finding of continuous symptoms of the claimed disabilities since service separation. Regarding the Veteran’s current claim of continuous or recurrent symptoms of the claimed disorders since service, the Board finds that, while the Veteran is competent to report the onset of symptoms of the claimed disorders, these more recent assertions are outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and are not reliable. See Charles v. Principi, 16 Vet. App. 370 (2002). The Board finds that the Veteran’s assertions of continuous or recurrent symptoms of bilateral hand, neck, bilateral knee, and bilateral ankle disabilities and sleep apnea after service are not accurate because they are outweighed by other evidence of record that includes the more contemporaneous service treatment records, which demonstrate that the hand lacerations during service resolved by the time of separation and are negative for the other claimed disorders; the lack of any documentation of reports or treatment for the claimed disorders until at least 2011, 4 years after service separation; the documentation of post-service neck and left ankle disabilities; the history of inception knee problems provided by the Veteran at the May 2015 VA examination; and the absence of post-service treatment for right ankle, left hand, and left knee disabilities, as outlined above. As such, the Board does not find that the evidence sufficiently supports continuous or recurrent symptomatology of the claimed disorders since service, so as to warrant a grant of service connection. Finally, the Board finds that the weight of the competent medical evidence weighs against a finding of a medical nexus between the current bilateral hand, neck, bilateral knee, and bilateral ankle disabilities and sleep apnea and active service. In this regard, the Board finds that the May 2015 VA nexus opinion, discussed above, is the most probative evidence of record. The VA opinion is competent and probative medical evidence because it is factually accurate and is supported by an adequate rationale. The VA examiner was informed of the pertinent evidence, reviewed the Veteran’s claims file, and fully articulated the opinion in the report, citing to specific treatment records in support of his conclusions. There are no contrary competent medical opinions of record. The Board acknowledges the Veteran’s belief that his bilateral hand, neck, bilateral knee, and bilateral ankle disabilities and sleep apnea are related to his active service. However, his statements alone do not establish a medical nexus. Indeed, while the Veteran is competent to provide evidence regarding matters that can be perceived by the senses, he is not shown to be competent to render medical opinions on questions of etiology. See Jandreau, 492 F.3d 1372; see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology). As such, as a lay person, he is without the appropriate medical training and expertise to offer an opinion on a medical matter, including the diagnosis, etiology, or causation of a specific disability. The question of diagnosis and causation, in this case, involves complex medical issues that the Veteran is not competent to address. Jandreau. Although the Veteran has not made any contention of an undiagnosed illness due to environmental or other exposure in Persian Gulf service, the RO conducted development in this regard because he served in Saudi Arabia. While the Board acknowledges that he may have been exposed to chemicals and other substances during his deployment in Southwest Asia, the medical evidence of record does not suggest a nexus relationship between any kind of exposure during active service and the claimed disorders, as noted by the June 2015 VA examiner. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Moreover, there is no evidence of an undiagnosed illness or qualifying chronic disability, as the claimed disorders are known and diagnosable conditions. Id. For these reasons, the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND The issue of entitlement to an initial disability rating in excess of 10 percent for the right shoulder strain is remanded. In the June 2015 rating decision on appeal, the RO granted service connection for a right shoulder strain and assigned an initial 10 percent disability rating. In his July 2015 notice of disagreement (NOD), the Veteran did not express disagreement with the initial rating assigned for the right shoulder disability; and the October 2015 statement of the case (SOC) did not address that issue. In August 2017, the Veteran filed a VA Form 21-526b, Supplemental Claim for Compensation, indicating he wished to file a claim for an increased rating for his right shoulder disability. However, in response, the RO indicated by way of an August 2017 letter that the right shoulder disability rating was already on appeal, and certified the issue to the Board on the April 2016 VA Form 8. Thus, the Veteran has been led to believe that the issue of the initial disability rating for the right shoulder is on appeal, and has been prevented by VA from pursuing a claim for a higher rating for the right shoulder because of the pending appeal. The Board finds, therefore, that since the RO has stated that the issue of entitlement to a higher initial disability rating for the right shoulder disability is on appeal and certified the issue to the Board, the Veteran is entitled to an SOC on the issue. See Manlincon v. West, 12 Vet. App. 238 (1999). In order to afford the Veteran due process, an SOC is necessary on the issue of entitlement to an initial disability rating in excess of 10 percent for the right shoulder strain. The matter is REMANDED for the following action: The RO shall consider the issue of entitlement to an initial disability rating in excess of 10 percent for the right shoulder strain. If the benefits sought cannot be granted, the RO should issue a statement of the case in accordance with applicable law and regulations. The Veteran and his representative should be informed of the period of time within which he must file a substantive appeal to perfect his appeal to the Board concerning this issue. If a timely substantive appeal is not filed, the claim should not be certified to the Board. If so, subject to current appellate procedures, the case should be returned to the Board for further appellate consideration, if appropriate. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Sherrard, Counsel