Citation Nr: 18146066 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 17-46 531A DATE: October 30, 2018 ORDER As new and material evidence has been received, the claim of entitlement to service connection for a lumbar spine disorder is reopened. As new and material evidence has been received, the claim of entitlement to service connection for a right knee disorder is reopened. As new and material evidence has been received, the claim of entitlement to service connection for a left knee disorder is reopened. Service connection for a right knee disorder is granted. Service connection for a left knee disorder is granted. Service connection for a lumbar spine disorder is denied. Service connection for a right ankle disorder is denied. Service connection for a left ankle disorder is denied. REMANDED Entitlement to service connection for a right shoulder disorder is remanded. Entitlement to a compensable rating for recurrent hemorrhoids post hemorrhoidectomy is remanded. FINDINGS OF FACT 1. In an October 2008 VA rating decision, the claims for entitlement to service connection for mild spondylosis of the lumbar spine and bilateral leg condition were denied; the Veteran was notified of this action and of his appellate rights and filed a timely notice of disagreement (NOD) in August 2009; the Regional Office (RO) issued a statement of the case (SOC) in May 2011; and the Veteran submitted an untimely substantive appeal in July 2011 and he was notified of this in September 2011. 2. The evidence received since the October 2008 VA rating decision regarding service connection for a right knee disorder is not cumulative or redundant and raises the possibility of substantiating the claim. 3. The evidence received since the October 2008 VA rating decision regarding service connection for a left knee disorder is not cumulative or redundant and raises the possibility of substantiating the claim. 4. The evidence received since the October 2008 VA rating decision regarding service connection for a lumbar spine disorder is not cumulative or redundant and raises the possibility of substantiating the claim. 5. The Veteran’s right knee disorder is as likely as not attributable to an in-service occurrence. 6. The Veteran’s left knee disorder is as likely as not attributable to an in-service occurrence. 7. The Veteran’s current lumbar spine disorder, diagnosed as lumbar spondylosis and arthritis, was not demonstrated in or related to an occurrence during active service and arthritis did not manifest to a compensable degree within one year of separation from service or noted to be chronic during service. 8. The Veteran’s current right ankle disorder, diagnosed as DJD, was not demonstrated in or related to an occurrence during active service and arthritis did not manifest to a compensable degree within one year of separation from service or noted to be chronic during service. 9. The Veteran’s current left ankle disorder, diagnosed as DJD, was not demonstrated in or related to an occurrence during active service and arthritis did not manifest to a compensable degree within one year of separation from service or noted to be chronic during service. 10. The Veteran is not currently service-connected for a bilateral foot disorder, to include pes planus. CONCLUSIONS OF LAW 1. The October 2008 VA rating decision denying entitlement to service connection for mild spondylosis of the lumbar spine and bilateral leg condition is final. 38 U.S.C. § 7105(b), (d) (2012); 38 C.F.R. §§ 3.104, 20.204, 20.302, 20.1103 (2018). 2. New and material evidence has been received since the October 2008 VA rating decision to reopen the claim for service connection for a lumbar spine disorder. 38 U.S.C. §§ 1110, 1131, 5108, 7104(b) (2012); 38 C.F.R. §§ 3.156, 3.303 (2018). 3. New and material evidence has been received since the October 2008 VA rating decision to reopen the claim for service connection for a right knee disorder. 38 U.S.C. §§ 1110, 1131, 5108, 7104(b); 38 C.F.R. §§ 3.156, 3.303. 4. New and material evidence has been received since the October 2008 VA rating decision to reopen the claim for service connection for a left knee disorder. 38 U.S.C. §§ 1110, 1131, 5108, 7104(b); 38 C.F.R. §§ 3.156, 3.303. 5. With resolution of reasonable doubt in the Veteran’s favor, the criteria for entitlement to service connection for a right knee disorder have been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303. 6. With resolution of reasonable doubt in the Veteran’s favor, the criteria for entitlement to service connection for a left knee disorder have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for entitlement to service connection for a lumbar spine disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 8. The criteria for entitlement to service connection for a right ankle disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 9. The criteria for entitlement to service connection for a left ankle disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from May 1961 to May 1965. Before reaching the merits of the claim for service connection for lumbar spine disorder, the Board must first determine whether new and material evidence has been received to reopen the previously denied claim. Jackson v. Principi, 265 F.3d 1366, 1369 (Fed. Cir. 2001). Therefore, the Board has recharacterized this issue accordingly. The claims for service connection for right and left knee disorders are based upon the same factual basis and symptoms as his original claim for service connection for bilateral leg condition, which the RO denied on the merits in an October 2008 VA rating decision. As such, it is appropriate for the Board to consider these claims as a request to reopen the previously denied claims. See Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008); see also Velez v. Shinseki, 23 Vet. App. 199, 204 (2009). With regard to the issues of service connection for lumbar spine, right ankle, and left ankle disorders on the merits, 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 a duty to assist argument). New and Material The Board has no jurisdiction to consider a claim based on the same factual basis as a previously disallowed claim. 38 U.S.C. § 7104(b); King v. Shinseki, 23 Vet. App. 464 (2010); DiCarlo v. Nicholson, 20 Vet. App. 52, 55 (2006). However, the finality of a previously disallowed claim can be overcome by the submission of new and material evidence. See 38 U.S.C. § 5108. New evidence means existing evidence not previously submitted to agency decision makers. Evidence that is merely cumulative of other evidence in the record cannot be new and material even if that evidence had not been previously presented to the Board. Anglin v. West, 203 F.3d 1343 (Fed. Cir. 2000). Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). 1. Right knee disorder 2. Left knee disorder 3. Lumbar spine disorder Due to the similar dispositions for the claims on appeal, the Board will address them in a common discussion below. In August 2007, the Veteran requested service connection for a back condition and a right leg condition. In October 2007, the Veteran also requested service connection for a left leg condition. In an October 2008 VA rating decision, service connection for mild spondylosis of the lumbar spine and a bilateral leg condition were denied because the evidence of record showed diagnoses of arthritis of the lumbar spine and knees did not manifest within one year of separation from active service, nor were they related to an in-service occurrence, but were rather due to weight gain and the aging process. The Veteran was notified of this action and of his appellate rights and filed a timely NOD in August 2009. The RO issued a SOC in May 2011, but the Veteran submitted an untimely substantive appeal in July 2011 and did not submit new and material evidence within a year thereafter. He was notified that his substantive appeal was untimely via a September 2011 letter. The October 2008 VA rating decision is final. See 38 U.S.C. § 7105(b), (d); 38 C.F.R. §§ 20.204, 20.302, 20.1103. Evidence received since the October 2008 VA rating decision includes an August 2014 private medical opinion from Dr. T. D. linking some of the Veteran’s current musculoskeletal problems and development of degenerative arthritis to repeated injuries in service. Additionally, a December 2010 private medical opinion from Dr. W. O. links the Veteran’s bilateral knee arthritis to his knee injuries in the past rather than an acute injury. The Board finds that this evidence is new and material to the element of establishing a nexus, which was not established at the time of the October 2008 VA rating decision. As a result, these claims are reopened. 38 U.S.C. §§ 1110, 1131, 5108; 38 C.F.R. §§ 3.156(a), 3.303. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. An injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the provisions of 38 C.F.R. § 3.303(b) apply only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a)). Service connection may be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection can also be established through application of statutory presumptions, including for “chronic diseases,” such as degenerative joint disease (DJD) and arthritis, when manifested to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). 4. Right knee disorder 5. Left knee disorder Due to the similar dispositions for the claims on appeal, the Board will address them in a common discussion below. The Veteran has a current diagnosis of bilateral knee DJD during the appeal period, as noted in a May 2013 VA Disability Benefits Questionnaire (DBQ) examination report for knee and lower leg conditions. As a result, the Board finds the element of a current disability has been met in this case. Throughout the course of the appeal, the Veteran reported the onset of his current bilateral knee disability while on active duty. He also asserted in-service injury while playing sports during service. Such assertions are noted in the August 2007 VA Form 21-526 and at the May 2018 Board hearing. Review of service treatment records shows that at the time of the Veteran’s examination, acceptance, and enrollment for military service, the May 1961 examination report documented clinical evaluation of his lower extremities was normal. On the May 1960 Report of Medical History, the Veteran marked “no” for having or ever having had a history of arthritis and “trick” or locked knee. During service, treatment records document a knee injury while playing football in August 1962 with clinical findings of generalized tenderness but no localizing signs of organic disease or pathology. Nevertheless, upon periodic examination in April 1962, clinical evaluation of his lower extremities was normal, and at the time of separation from service, the May 1965 examination report documented clinical evaluation of his lower extremities was normal, and on the May 1965 Report of Medical History the Veteran marked “no” for having or ever having had a history of arthritis and “trick” or locked knee. As a result, the Board finds the element of an in-service occurrence has been met in this case. As noted above, the Veteran was afforded a VA DBQ examination for knee and lower leg conditions in May 2013. Following a review of the claims file and in-person examination, the VA examiner concluded the Veteran’s bilateral knee disorder was not incurred in or caused by playing football during active service in 1962 and explained the following: There is documentation from the Veteran’s orthopedic physician that in 2000 he has ‘osteoarthritis from obesity.’ He had no DJD in service nor [within a year] after service. The Veteran’s [body mass index] is greater than 50 which predisposes him to DJD of weight bearing joints. He has had [body mass index] greater than 45-50 for past 15 or more years which has contributed to his lower joint osteoarthritis. On the other hand, review of the record shows that in the December 2010 private statement Dr. W. O. reported the following: I recently evaluated [the Veteran] who is status left total knee replacement... He has advanced arthritis of the right knee.... I feel that after reviewing his previous histories that his advanced osteoarthritis of his knees was not traumatic; that is to say, it was not secondary to an acute injury and is more likely accumulative result of injuries to his knees in the past. The Board finds that these May 2013 VA and December 2010 private medical opinions are competent and probative medical evidence as it appears that both physicians relied on accurate facts and medical history and gave fully articulated opinions supported by sound reasoning. As such, there is both favorable and unfavorable evidence of record that bears on the question of a nexus between the Veteran’s right and left knee disorders and in-service occurrence. Resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for right and left knee disorders on a direct basis is warranted. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.303. 6. Lumbar spine disorder The Veteran has current diagnoses of lumbar spondylosis and arthritis during the appeal period, as noted in a May 2013 VA DBQ examination report for back (thoracolumbar spine) conditions. As a result, the Board finds the element of a current disability has been met in this case. Review of service treatment records shows that evaluation at the time of entrance to and separation from his period of service did not reveal any lumbar spine abnormality. On an enlistment examination report dated in May 1961 and separation examination report dated in May 1965, his spine evaluation was recorded as normal. He also marked “no” for having or ever having had a history of arthritis in Reports of Medical History dated in May 1961 and May 1965. Upon periodic examination in April 1962, clinical evaluation of his spine was normal. Nevertheless, during service, treatment records document that in September 1961 the Veteran fell on his back while sitting in a chair and hit a trash can and diagnostic testing of the lower thoracic and lumbar spine revealed no significant abnormality (NSA). Low back pain was also documented in March 1962 and May 1965. Moreover, the Veteran reported hurting his back while playing sports during active service in an August 2007 VA Form 21-526 and at the May 2018 Board hearing. As a result, the Board finds the element of an in-service occurrence has been met in this case. Since separation from active service, an August 2000 private treatment record noted the Veteran’s low chronic back pain by history. A January 2001 private treatment records shows the Veteran presented with a history of lifting a 55-gallon drum on a dolly at Pennzoil plant and was diagnosed and treated for an acute lumbar strain. This was a post-service injury. An August 2003 private treatment record also documented an assessment of low back strain. At a September 2008 VA examination for the spine, the Veteran reported continuous low back pain due to an in-service injury while playing football in 1963. Following a review of the Veteran’s claims file and in-person examination, the VA examiner rendered a diagnosis of age-related mild spondylosis of the lumbar spine and concluded it is not as likely as not that the Veteran’s lumbar spine condition is caused by or a result of military service. It was explained, in part, that the causes of the lumbar spine condition, to include degenerative changes of the spine, are the aging process and his morbid obesity or significant weight gain. In response to the September 2008 VA medication opinion, the Veteran asserted in the July 2011 substantive appeal that he took steroids for many years to relieve his back pain which he understands promotes weight gain. He also reported at the May 2018 Board hearing that he gained weight as result of having to eat while taking medication. The Board acknowledges that VA’s General Counsel recently held that obesity may act as an “intermediate step” between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310(a). VAOPGCPREC 1-2017 (Jan. 6, 2017). In this case, however, neither the Veteran nor the evidence of record indicates his weight gain was an “intermediate step” between his lumbar spine disorder and an already service-connected disability. In fact, the Veteran asserts his weight gain was the direct cause of his lumbar spine disorder. Next, as previously noted, an August 2014 private medical opinion from Dr. T. D. linked some of the Veteran’s current musculoskeletal problems and development of degenerative arthritis to repeated injuries in service. The Board finds this opinion is general and does not specifically address the Veteran’s current lumbar spine disorder and in-service occurrence. In April 2018, the Veteran submitted a medical opinion form completed by a private physician who noted the Veteran’s back condition is at least as likely as not caused by or a result of active duty. The Board finds this opinion was not supported by a rationale. Moreover, Dr. T. D. provided an additional conclusion in May 2018 explaining why an opinion regarding the etiology of the Veteran’s current back symptomatology could not be provided “without resorting to mere speculation.” Medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see Warren v. Brown, 6 Vet. App. 4, 6 (1993). At the May 2013 VA DBQ examination for back conditions, the Veteran reported injuring his back when he fell out of a chair during service in 1962. He also noted having worsening back pain since that injury and over time the pain has gotten progressively worse. Following a review of the Veteran’s claims file and in-person examination, the VA examiner rendered a diagnosis of lumbar spondylosis, noted clinical findings of arthritis, and concluded the Veteran’s lumbar spondylosis was not incurred in or caused by in-service injury that occurred in September 1961. It was explained that: Records show that the Veteran has documented history of ‘lifting a 55-gallon drum on dolly at Pennzoil plant and strained his lower back.’ He also complained of tightness across lower back with no radiation. This was several years after military service in 2001. He was then diagnosed with an acute lumbar strain. A strain resolves and he now has evidence of spondylosis which is a separate entity from a strain. There was no spondylosis noted in military service nor in presumptive period after service. Based on the evidence of record, there is no probative and competent evidence that demonstrates this current lumbar spine disorder was demonstrated in or related to an occurrence during active service, to include the documented injury in September 1961 and pain in March 1962 and May 1965. 38 C.F.R. § 3.303. In sum, the Board finds that the evidentiary record does not contain positive probative evidence to establish that the third criterion to establish service connection on a direct basis has been met. The Board also finds the evidence is against a finding that arthritis of the lumbar spine manifested to a compensable degree within one year of separation from active duty or was chronic during service. While the Veteran informed the May 2013 VA examiner that he has had worsening back pain since his in-service injury, review of post-service treatment records shows initial assessments of back pain in August 2000, low back strain in January 2001, and degenerative changes in the lumbar spine in August 2004, which is still multiple years after separation from service. As a result, such evidence is not competent to establish the presence of arthritis within one year of separation from service. Accordingly, service connection for lumbar spine disorder on a presumptive basis as a chronic disease is not warranted. See 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a). Moreover, in light of the onset of this current disability after separation from service, the Board finds that lumbar spine disorder did not have onset during service to warrant service connection. See 38 C.F.R. § 3.303(d). Lastly, in the August 2014 private medical opinion, Dr. T. D. further reported [t]here are also some studies that show a correlation between pes planus and . . . low back pain.” In May 2018, the Veteran submitted a medical opinion form completed by a private physician who noted the Veteran’s back condition is most likely caused by or a result of pes planus. The Veteran also asserted a link between his flat feet and lumbar spine disorder, as noted in an August 2011 statement and at the May 2018 Board hearing. After review of the record, the Board finds that the Veteran is not currently service-connected for a bilateral foot disorder, to include pes planus, nor is the issue to reopen service connection for a bilateral foot disorder, to include pes planus, currently on appeal. Accordingly, service connection for lumbar spine disorder as on a secondary basis is not warranted. See 38 C.F.R. § 3.310 (2018). The Board has considered the Veteran’s reported history of symptomatology related to his lumbar spine disorder throughout the appeal period. He is competent to report such symptoms and observations because this requires only personal knowledge as it comes through an individual’s senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). His description of his symptoms is also credible. Because there is no universal rule as to competence on this issue, the Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person to provide an opinion as to etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376 -77 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). In this case, the lay statements of record do not rise to a level of competency to offer a probative opinion as to the etiology of the Veteran’s diagnosed lumbar spondylosis and arthritis and are not competent to state that the symptoms he experienced over time are the result of his in-service occurrence as opposed to another intervening cause such as obesity or a post-service injury. Determining the etiology of the Veteran’s current lumbar spine disorder requires inquiry into internal physical processes which are not readily observable and not within the competence of the Veteran in this case. The evidence does not show that he has the skills, training, or medical experience needed to make such a determination. As a result, the probative value of his lay assertions is low and the lay statements are outweighed by the medical evidence. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against this claim, the doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 7. Right ankle disorder 8. Left ankle disorder Due to the similar dispositions for the claims on appeal, the Board will address them in a common discussion below. The Veteran has a current diagnosis of bilateral ankle DJD during the appeal period, as noted in a May 2013 VA DBQ examination report for ankle conditions. As a result, the Board finds the element of a current disability has been met in this case. Review of service treatment records shows that evaluation at the time of entrance to and separation from his period of service did not reveal any ankle abnormalities. On an enlistment examination report dated in May 1961, his lower extremities were recorded as normal and pes planus was noted as an abnormality of his feet, and on a separation examination report dated in May 1965, his lower extremities and feet were record as normal. He also marked “no” for having or ever having had a history of arthritis or foot trouble in Reports of Medical History dated in May 1961 and May 1965. Upon periodic examination in April 1962, clinical evaluation of his lower extremities and feet were normal. Nevertheless, during service, treatment records document left ankle sprains in January 1964 and November 1964. Particularly, in November 1964, the sprain occurred while playing basketball, and clinical findings showed the ankle was very swollen, he demonstrated limited range of motion, and was treated by whirlpool and active range of motion exercises. Moreover, the Veteran reported hurting both ankles while playing sports during active service. As a result, the Board finds the element of an in-service occurrence has been met in this case. Since separation from active service, a May 2006 private treatment record noted the Veteran presented with worsening edema of the ankles. A May 2006 VA treatment record also noted the Veteran’s complaint of bilateral ankle swelling. At the May 2013 VA DBQ examination for ankle conditions, the Veteran reported that during active service he played football during intramural sports for physical training and acquired several left ankle twists and sprains that were treated conservatively. He has never had ankle surgery, but reported the presence of pain and swelling after prolonged weight bearing throughout his lifetime. Following a review of the Veteran’s claims file and in-person examination, the VA examiner rendered a diagnosis of left ankle DJD, noted clinical findings of arthritis in both ankles, and concluded the Veteran’s left ankle condition is not incurred in or caused by in-service injury that occurred in November 1964. It was explained that: The Veteran has bilateral DJD of ankles and no DJD was noted in military service nor in presumptive period after service. The Veteran’s [body mass index] is greater than 50 which predisposes him to DJD of weight bearing joints. He has had [body mass index] greater than 40-50 for past 15 or more years which has contributed to his lower joint osteoarthritis. Based on the evidence of record, there is no probative and competent evidence that demonstrates these current ankle disorders were demonstrated in or related to an occurrence during active service, to include the documented left ankle sprains in January 1964 and November 1964 and reported injury to both ankles while playing sports. 38 C.F.R. § 3.303. In fact, the May 2013 VA medical opinion carries significant weight as the examiner provided a sufficient rationale for the etiology of the right and left ankle disorders. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012) (holding that there is no requirement that a medical examiner comment on every favorable piece of evidence in a claims file and a medical report “must be read as a whole” to determine examiner’s rationale); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). In sum, the Board finds that the evidentiary record does not contain positive probative evidence to establish that the third criterion to establish service connection on a direct basis has been met. The Board also finds that the evidence is against a finding that DJD of the ankles manifested to a compensable degree within one year of separation from active duty or was chronic during service. While May 2006 treatment records documented swelling in the ankles, review of the record documents the initial finding of degenerative changes in the ankles in May 2013, which is multiple years after separation from service. As a result, such evidence is not competent to establish the presence of DJD within one year of separation from service. Accordingly, service connection for right and left ankle disorders on a presumptive basis as chronic diseases is not warranted. See 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a). Moreover, in light of the onset of these current disabilities after separation from service, the Board finds that right and left ankle disorders did not have onset during service to warrant service connection. See 38 C.F.R. § 3.303(d). Lastly, the Veteran asserts a link between his flat feet and ankle disorders, as noted at the May 2018 Board hearing. As noted above, the Veteran is not currently service-connected for a bilateral foot disorder, to include pes planus, nor is the issue to reopen service connection for a bilateral foot disorder, to include pes planus, currently on appeal. Accordingly, service connection for right and left ankle disorders on a secondary basis is not warranted. See 38 C.F.R. § 3.310. The Board has considered the Veteran’s reported history of symptomatology related to his right and left ankle disorders throughout the appeal period. His descriptions of his ankle symptoms are both competent and credible. See Layno, 6 Vet. App. at 470; Jandreau, 492 F.3d at 1376 -77; see also Kahana, 24 Vet. App. at 428. In this case, the lay statements of record do not rise to a level of competency to offer a probative opinion as to the etiology of the Veteran’s diagnosed DJD of the ankles and are not competent to state that the symptoms he experienced over time is the result of his in-service occurrence. Determining the etiology of the Veteran’s current right and left ankle disorders on a direct basis requires inquiry into internal physical processes which are not readily observable and not within the competence of the Veteran in this case. The evidence does not show that he has the skills, training, or medical experience needed to make such a determination. As a result, the probative value of his lay assertions is low and the lay evidence is outweighed by the medical evidence of record. In reaching this decision the Board considered the doctrine of reasonable doubt, however, as the preponderance of the evidence is against these claims, the doctrine is not for application. Gilbert, 1 Vet. App. at 49. REASONS FOR REMAND 1. Entitlement to service connection for a right shoulder disorder Following a May 2013 VA DBQ examination for shoulder and arm conditions, the VA examiner rendered a diagnosis of DJD and explained why it is less likely than not incurred in or caused by in-service right shoulder injury in April 1963. Subsequently, in an August 2014 private medical opinion, Dr. T. D. noted the Veteran’s in-service right shoulder injury and asserted that some of the Veteran’s current musculoskeletal problems and development of degenerative arthritis to repeated injuries in service. Moreover, the Veteran reported at the May 2018 Board hearing that his right shoulder has gotten worse over time and he started taking prescribed medication after separation from ative service. In light of these assertions, an additional VA medical opinion is needed to properly adjudicate this claim on appeal. See 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. § 3.303 (2018); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). 2. Entitlement to a compensable rating for recurrent hemorrhoids post hemorrhoidectomy During the course of the appeal, the Veteran was afforded VA DBQ examinations for rectum and anus conditions in January 2011 and May 2013. Since then, at the May 2018 Board hearing, the Veteran reported his leakage problem comes and goes, he watches what he eats, uses and changes a pad about three to five times a day during a flare up, and self-medicates to avoid external hemorrhoids and constant bleeding. The Veteran has provided credible examples of how his hemorrhoid disability has increased in severity since his last VA examination, which was provided five years ago. In light of these findings, a new examination is needed to determine the current severity of his hemorrhoid disability. Weggenmann v. Brown, 5 Vet. App. 281, 284 (1993); see also 38 C.F.R. § 3.326 (a) (2017). The matters are REMANDED for the following actions: 1. Return the Veteran’s claims file to the examiner who conducted the May 2013 VA DBQ examination for shoulder and arm conditions so a supplemental opinion may be provided. If that examiner is no longer available, provide the Veteran’s claims file to a similarly qualified clinician. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. A new examination is only required if deemed necessary by the examiner. The examiner must provide an opinion as to whether or not the medical opinion rendered in May 2013 for right shoulder disorder (even if diagnosis of DJD has since resolved) has changed after a complete review of the Veteran’s claims file, to include consideration of the August 2014 private medical opinion from Dr. T. D. and the Veteran’s lay assertions of post-service prescribed treatment at the May 2018 Board hearing. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Schedule the Veteran for an examination with an appropriate clinician to determine the current severity of his recurrent hemorrhoids post hemorrhoidectomy. The entire claims file and a copy of this remand must be made available to the examiner for review, and the examiner must specifically acknowledge receipt and review of these materials in any reports generated. 3. Then, review the examination reports and medical opinions to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the RO must implement corrective procedures. 4. Then, readjudicate the claims. If any decision is unfavorable to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD T. Carter, Counsel