Citation Nr: 18152585 Decision Date: 11/23/18 Archive Date: 11/23/18 DOCKET NO. 16-11 822 DATE: November 23, 2018 ORDER Entitlement to service connection for left hallux valgus with bunion, to include as due to contaminated water at Camp Lejeune, is denied. Entitlement to service connection for right hallux valgus with bunion, to include as due to contaminated water at Camp Lejeune, is denied. Entitlement to service connection for headaches, to include as due to contaminated water at Camp Lejeune, is denied. Entitlement to service connection for a disorder manifested by rectal bleeding is denied. Entitlement to service connection for nerve damage of the chest is denied. Entitlement to service connection for erectile dysfunction is denied. Entitlement to service connection for a sleep disorder, claimed as difficulty sleeping, is denied. Entitlement to service connection for a disorder of the left hand is denied. Entitlement to service connection for a disorder of the right hand is denied. Entitlement to service connection for a disorder of the left arm and elbow, claimed as pain, is denied. Entitlement to service connection for a disorder of the right arm and elbow, claimed as pain, is denied. Entitlement to service connection for a right knee disorder, claimed as due to service-connected left knee disability, is denied. Entitlement to an evaluation in excess of 10 percent for a left knee disorder is denied. Entitlement to an initial compensable rating for bilateral calluses is denied. FINDINGS OF FACT 1. Left and right hallux valgus with bunions are first shown years after active service and are unrelated to the Veteran’s military service, including to contaminated water at Camp Lejeune at which he had been stationed. 2. Headaches are first shown years after active service and is unrelated to the Veteran’s military service, including to contaminated water at Camp Lejeune. 3. The evidence of record demonstrates no association between the post service chronic rectal bleeding, which is due to the post service onset of hemorrhoids, and military service. 4. The Veteran is service-connected for post-operative scarring of his chest from inservice incision and drainage of a pleural abscess, but separate neurologic disability is not shown by the evidence of record. 5. The Veteran’s reported erectile dysfunction is no more than diminished libido which is consistent with the aging process. 6. A sleep disorder of service origin, claimed as difficulty sleeping, is not demonstrated by the evidence of record. 7. A disorder of the left and right hands is first shown years after service and is unrelated to military service. 8. A disorder of the left and right arms and elbows, claimed as pain, is first shown years after service and is unrelated to military service. 9. A right knee disorder is first shown years after active service and is unrelated to military service; and is not proximately due to or aggravated by the Veteran’s service-connected left knee disorder. 10. For the entire appeal period, the Veteran's left knee disability is productive of full extension and flexion without pain limited to no less than 120 degrees, including on repetitive testing, and results in no more than slight instability. 11. The Veteran’s bilateral calluses do not involve an area of 5 percent of the total body surface or 6 square inches, do not equate with symptomatic scarring, and are not productive of functional impairment. CONCLUSIONS OF LAW 1. The criteria for service connection for left hallux valgus with bunion, to include as due to contaminated water at Camp Lejeune, are not met. 38 U.S.C. §§ 1101, 1112, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2018). 2. The criteria for service connection for right hallux valgus with bunion, to include as due to contaminated water at Camp Lejeune, are not met. 38 U.S.C. §§ 1101, 1112, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2018). 3. The criteria for service connection for headaches, to include as due to contaminated water at Camp Lejeune, are not met. 38 U.S.C. §§ 1101, 1112, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2018). 4. The criteria for service connection for a disorder manifested by rectal bleeding are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 5. The criteria for service connection for nerve damage of the chest are not met. 38 U.S.C. §§ 1101, 1112, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 6. The criteria for service connection for erectile dysfunction are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 7. The criteria for service connection for a sleep disorder, claimed as difficulty sleeping, are not met. 38 U.S.C §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 8. The criteria for service connection for a disorder of the left hand are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 9. The criteria for service connection for a disorder of the right hand are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 10. The criteria for service connection for a disorder of the left arm and elbow, claimed as pain, are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 11. The criteria for service connection for a disorder of the right arm and elbow, claimed as pain, are not met. 38 U.S.C. §§ 1131, 5107 (2015); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 12. The criteria for service connection for a right knee disorder, claimed as due to service-connected left knee disability, are not met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2018). 13. The criteria for an evaluation in excess of 10 percent for a left knee disorder are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5003, 5256-5263 (2018). 14. The criteria for an initial compensable rating for bilateral calluses are not met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.6, 4.7, 4.10, 4.21, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 7806 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1982 to October 1989. This appeal to the Board of Veterans’ Appeals (Board) arose from rating decisions of November 2012 and April 2013 of a Department of Veterans Affairs (VA) Regional Office (RO). In the May 2013 Notice of Disagreement (NOD), the Veteran stated that he had never related the claims for service connection for hallux valgus with bunions of each foot to contaminate water at Camp Lejeune. In the VA Form 9 of February 2016, the Veteran stated that those claims and the claim for service connection for headaches were “never initially” claimed in association with Camp Lejeune contaminated water. By stating “initially” it is presumed that the Veteran has not abandoned this theory of entitlement and, so, it will be addressed herein. Background Service personnel records show that the Veteran was stationed at Camp Lejeune from September 13, 1982, to June 1, 1983; throughout much of 1985 and 1986; and again in 1989. Examination in June 1981 for enlistment revealed no pertinent abnormality. In August 1982 the Veteran received an electrical shock to his right hand. On examination his right hand was within normal limits. The assessment was status post (SP) electric shock and dyshydrosis of both hands. He was returned to duty that same day. In August 1983 the Veteran underwent incision and drainage of an abscess of his left chest wall. In September 1983 the Veteran was seen for follow-up wound care after having had a left thoracotomy for drainage of a pleural abscess. The wound was clean and dry, with good granulation. In October 1983 there was no sign of infection of the surgical wound. Also in October 1983 a cystic abscess at the base of the Veteran’s penile shaft was drained, and he was given antibacterial medication. The Veteran was hospitalized in October 1983 for left groin pain and an ulcerated wound of the penile shaft. On examination he had an ulceration on the left and the right sides of the penile shaft. He was treated with antibacterial medication. The admitting and discharge diagnosis was a chancroid with left inguinal bubo. In June 1984 the Veteran was treated for multiple venereal warts. In November 1984 he had urethral discharge due to a sexually transmitted disease (STD), which in December 1984 was noted to have resolved. In November 1984 and March 1985 the Veteran was seen for venereal warts. In July 1985 the Veteran complained of pain in the back of the right leg and stated that he had felt a muscle pull while learning to ski the day before. He had no history of right leg pain. On examination he had slight pain on range of motion and walked with a slight limp. The assessment was a pulled right leg muscle, for which he was given medication for pain. On re-enlistment examination in August 1985 it was reported that the Veteran had pes planus. In January 1987 the Veteran complained of having a tingling sensation upon urination. Discharge had been noted in his underwear and he stated that his urine was a darker yellow than usual. An assessment later that day was that a sexually transmitted disease (STD) was to be ruled out. In March 1987 it was reported that the Veteran had calluses on the weight-bearing areas of both feet. The calluses were shaved down. He was also seen that month for iliotibial band syndrome of the left knee. In January 1988 the Veteran had right shoulder pain after lifting weights. The location of the pain was from the right side of the neck down to the right shoulder. X-rays were negative and after an examination the assessment was a right shoulder sprain. He was given a sling and limited duty for 10 days. In February 1988 the Veteran sustained a punctate laceration of the palm of his left hand. The wound was cleaned and bandaged. The assessment was a punctate wound of the left palmar area. A February 1988 medical history questionnaire shows that the Veteran reported having or having had swollen or painful joints; skin disease; cramps in his legs; broken bones; a tumor, growth or cancer; a venereal disease; and foot trouble. He denied having or having had piles or rectal disease; frequent or painful urination; arthritis, rheumatism or bursitis; bone, joint or other deformity; lameness; trick or locked knee; neuritis; and frequent trouble sleeping. However, it was reported that he had had leg cramps from overexertion. He had had a fracture of the right 5th finger and left great toe from playing football but did not have any residuals problems. In May 1988 the Veteran complained of pain in his left testicle. An examination found no abnormality and the assessment was a probably trauma induced mild testicular pain. In September 1988 the Veteran sustained and was treated for a puncture injury, from a needle, of the distal interphalangeal joint (DIP) of the left great toe. In March 1989 the Veteran had blood in his stool, having had diarrhea all morning, although he had not had pain with bowel movements. On examination he had a small hemorrhoid. The assessment was “diarrhea – probably infection.” When seen for a follow-up the next day it was reported that his rectal bleeding had resolved after his last episode of diarrhea 24 hours earlier. He was followed-up again later that month when it was reported that he had not had any further rectal bleeding or diarrhea. The assessment was resolved rectal bleeding. In May 1989 the Veteran complained of left knee pain and the assessment was ilio-tibial band syndrome. In June 1989 the Veteran sustained a laceration of the left 3rd finger. He had minimal bleeding and a small area of avulsion of the tip of the finger. There was tenderness on palpation but full range of motion. The assessment was a superficial avulsion of the left 3rd finger. A small flap of skin was removed. On examination for service separation in August 1989 it was noted that the Veteran had had an incision on the left side of his chest for removal of a cyst and had partial removal of a rib. No other abnormality was found. The Veteran’s original claim for VA disability compensation was received in October 1989, in which he claimed service connection for removal of a cyst from his left chest wall, left knee disability, and a perforated right eardrum. On VA examination in December 1989 the Veteran’s pertinent complaints included left knee pain. His carriage, posture, and gait were normal. The examiner noted that an expanding cyst had been noted in the Veteran’s left lung in 1983 and was excised but a current physical examination was normal except for a scar, typical for a thoracotomy during which, apparently, a rib had been removed. The Veteran’s chest wall was normally mobile and there was no pathology to palpation, percussion, and auscultation. He had no hemorrhoids and there was no other rectal pathology. His seminal vesicles, testes, spermatic cord, and penis were perfectly normal. His prostate was not enlarged or nodular. There was no penile discharge. At the examination the Veteran reported that his constant left knee pain had progressively worsened. On examination range of motion was normal but there was subjective tenderness, laterally. His motor status was normal and his coordination and reflexes were normal. His sensory status and equilibrium were good. The diagnoses were possible chondromalacia of the left knee, and SP excision of left lung cyst. VA X-rays of both knees in December 1989 showed no significant bone or joint abnormality in the right knee joint, but there was cortical thickening of the distal left femur, on the posterior aspect. Entered into VBMS, and dated January 22, 1990, are records which indicate that the Veteran was stationed at Camp Lejeune from September 1982 to October 1989, and that he lived and worked on base. On VA orthopedic examination of the Veteran’s left knee in December 1991 the Veteran complained of pain of the lateral aspect of his left knee with most activity but no giving way. On examination there was no abnormality of his station or gait. He had 140 degrees of flexion and hyperextension of 5 degrees but there was no instability. There was tenderness to palpation of the lateral joint line. McMurray’s sign was considered to be negative. He performed satisfactory heel and toe walk, and could perform a full squat and arise again. The diagnosis was chronic left knee pain of uncertain etiology, and a lateral meniscus tear was to be considered. A left knee X-ray was essentially within normal limits. Private clinical records, received in 2011, include a January 2000 colonoscopy at the Baptist Hospital revealed a normal anus and rectum but there were very rare diverticula of the Veteran’s transverse colon. The descending colon, sigmoid, and anus were normal except for moderate internal hemorrhoids. The impressions were internal hemorrhoids, mild diverticulosis but an otherwise normal colon to the cecum. A February 2002 record of the Gulf Coast Orthopaedic Specialists shows that about 3 months earlier the Veteran banged his left elbow and now felt that he was bumping the left elbow all the time and the swelling had been constant. There was no prior left elbow injury. The impression was left olecranon bursitis, and that joint was aspirated. An October 2003 private clinical record noted that the Veteran had nasal obstruction and heavy snoring, and his wife had reported that he had snored heavily for the past year. A November 2003 CT scan of his sinuses revealed nasoseptal deviation slightly to the right, and minimal decrease in the right maxillary sinus most likely related to polypoid mucosal thickening and less likely due to a polyp or retention cyst. The Veteran underwent a private evaluation in May 2004 for intermittent rectal bleeding which he had had for several months. On examination there was no cyanosis, clubbing or edema of his extremities. His gait was normal. An anoscopy revealed first degree internal hemorrhoids. However, they were not such as to warrant surgery at that time. Private clinical records show that in October 2004 the Veteran was diagnosed as having chronic allergic rhinosinusitis. In April 2005 the Veteran had surgery, a septoturbinoplasty, for rhinitis and sinusitis, with nasal obstruction and heavy snoring. He had not had problems with sleep apnea of which he or his wife were aware. In October 2005 Dr. K. Turnage reported that without known trauma the Veteran had begun having popliteal and lateral right knee discomfort which had steadily worsened. An X-ray revealed a little bit of varus alignment of the right knee. In July 2006 the Veteran had a medial meniscectomy of the right knee, when it was also noted that he had a lateral meniscus tear and cartilage defect of the medial femoral condyle. A December 2006 right knee MRI revealed findings consistent with a partial right medial meniscectomy, mild chondromalacia of the right medial condyle, and a large amount of effusion and small popliteal cyst. A December 2006 private treatment record noted that the Veteran had had a chondroplasty of the posterior aspect of the right medial femoral condyle and partial medial meniscectomy and partial minimal lateral meniscectomy, (which was done in July 2006) and he had now returned for evaluation three months after being released to return to work. Postoperatively, he had recurrent swelling without any specific injury. An MRI was recommended. A December 2006 MRI of the Veteran’s right knee at the Gulf Coast Orthopaedic Specialists reflects that while no history was provided the Veteran related having had surgery in July 2006, and the development of symptoms a few weeks ago. The conclusion was that the MRI revealed a medial meniscus appearance consistent with a partial meniscectomy without evidence of a re-tear; mild chondromalacia of the medial condyle; and a large amount of effusion and a small popliteal cyst. In 2007 the Veteran was evaluated at the Baptist Hospital for an inflamed and infected cyst on the right side of his chest, and which had been treated with antibiotics. On examination he had a mobile but very small nodule on the right side of his chest. It was suspected that this was “an EIC” [epidermal inclusion cyst]. The cyst was to be excised from the right side of his chest. Private clinical records, received in 2011, include a report of a January 2009 colonoscopy which revealed a small posterior fissure of the rectum. There were a few scattered diverticula of the colon, hepatic flexure, and transverse colon. There was moderate diverticulosis of the sigmoid colon. The impressions were hemorrhoids, a small posterior anal fissure, and diverticulosis. The Veteran was seen in January 2009 by the Gastroenterology Associates of Pensacola for rectal bleeding and occasional loose stools. It was noted that the past January 2000 colonoscopy had revealed internal hemorrhoids and mild diverticulosis. He denied altered urinary function but his neurologic system was significant for headaches. In February 2010 the Veteran had a private evaluation for intermittent rectal bleeding, when it was reported that a colonoscopy a year ago had revealed some diverticula. A current anoscopy revealed first degree internal hemorrhoids. The Veteran was seen in February 2010 for a three week history of left elbow pain. In his work he did a lot of heavy lifting and a lot of crimping of wires. He had pain in the lateral aspect of the left elbow which radiated into the forearm and down into his hand, particularly when lifting or using crimping tools. X-rays revealed a fairly prominent olecranon spur. The impression was severe lateral epicondylitis of the left elbow, for which he was to receive an injection of Kenalog. In June 2010 the impressions, following an examination, were fulminant/recalcitrant left-sided lateral epicondylitis, recalcitrant to steroid injection, and possible left posterior interosseous nerve entrapment. He was referred to a neurosurgeon for possible posterior interosseous nerve decompression and/or tennis elbow release. When seen in July 2010 by the neurosurgeon, R. Noellert, M.D., it was reported that the Veteran’s insidious development of lateral sided left elbow pain came about in the course of his day-today activities and not from a specific injury. After an examination the impression was left elbow lateral epicondylitis with some components of radial tunnel syndrome. Received in February 2012 were private clinical records of a private podiatrist, S. Rickoff, D.P.M., reflecting treatment of the Veteran’s feet from January to December 2011. Cumulatively, these show that he had a repeated diagnosis of porokeratosis. Porokeratosis is a rare, chronic, progressive autosomal dominant skin disorder, seen most often in males, usually first appearing in early childhood, and characterized clinically by the presence of crater-like patches with central atrophy and an elevated thick keratotic border that enlarge to form circinate, serpiginous, or gyrate lesions, and histologically by a cornoid lamella. Dorland’s Illustrated Medical Dictionary, 27th Ed., page 1337. Porokeratosis is a hereditary dermatosis marked by a spreading hypertrophy of the stratum corneum around the sweat pores followed by atrophy. Dorland’s Medical Dictionary, 1980, page 550. The 2011 private podiatrist’s records show that the Veteran repeatedly underwent ultrasound therapy to the plantar aspect of the 5th metatarsophalangeal joints of both feet, and the plantar aspect of his right heel, as well as debridement and chemocautery. In April 2011 the neurosurgeon, R. Noellert, M.D., reported that the Veteran had a new complaint of right 5th finger and right hip pain. He had a longstanding deformity of the PIP joint of the right 5th finger following a remote trauma while in high school. Over the past few months he had had stiffness and swelling without recent injury. X-rays revealed minimal joint space narrowing at the right 5th PIP joint. The impressions included recurrent lateral epicondylitis/radial tunnel syndrome of the left elbow, and exacerbation of longstanding right 5th finger PIP arthropathy. A May 2011 record by R. Noellert, M.D., shows that the Veteran complained of occasional numbness of the left hand. After an examination the impressions include possible carpal tunnel syndrome (CTS). In August 2011 he had a more global feeling of left arm pain, left hand numbness, and subjective weakness. It was also reported that sleep disturbance “is now more typical.” After an examination the impressions were refractory left elbow lateral epicondylitis, left CTS, and probable left elbow ulnar neuropathy. However, a report of electrodiagnostic studies shows that the Veteran had had an approximately one year history of pain of the left lateral epicondyle, and the studies found no electrophysiologic evidence of left CTS or left ulnar neuropathy at the elbow. In October 2011 it was noted that about a week earlier he had had radial nerve decompression for epicondylitis and extensor tendon lengthening of the left elbow. In VA Form 21-4138, Statement in Support of Claim, dated November 21, 2011, the Veteran clarified that he was claiming service connection for rectal bleeding and not for erectile bleeding and stated that “[t]here is no erectile medical condition.” In a VA Form 21-4138, Statement in Support of Claim, dated in November 2011 the Veteran reported that his rectal bleeding started during military service and increased in severity after service. In another such statement at that time he reported that post surgery scar tissue (from inservice excision of a cyst from the left side of his chest) had possibly caused decreased lung capacity, and period pain and nerve issues “at this central location” which warranted concern. In another such statement at that time he reported that his left knee disability had caused him to place greater weight on his right knee, leading to right knee disability. The Veteran was afforded several VA examinations on August 7, 2012, at which time the examiner reviewed the claim file. The examiner reported that the Veteran’s skin was warm and dry, with good skin color and normal turgor and without ecchymosis, jaundice or breakdown. There were no skin changes, including the feet. His posture and gait were normal, and he did not need an assistive device for ambulation. There was no muscle atrophy or loss of muscle tone, and strength testing was normal. With respect to the Veteran’s knees the examiner reported that loss of function due to flare-ups could not be determined without resorting to speculation. Specifically, on examination of the Veteran’s knees and lower legs the Veteran reported that over the years he had had left knee limitation of motion and occasional pain but it had progressed such that the knee now hurt most of the time and he was unable to bend the left knee for any period of time. Because of his left knee pain, he could not kneel or stoop. However, he had not seen a physician for his left knee in recent years. As to his right knee, he reported that in the past it had been his good knee but he had had three (3) tears of menisci, for which he had right knee surgery in 2005. He had had some improvement after the right knee surgery but now had pain, which he believed was due to arthritis. The Veteran did not report having flare-ups which impacted function of a knee. On physical examination the Veteran had left knee flexion which was painless to 120 degrees and full extension to 0 degrees without objective evidence of pain. After three repetitions of motion, left knee flexion was to 130 degrees and extension remained full to 0 degrees and, thus, he had no additional limitation of motion after repetitive use testing. He did have functional loss or impairment due to limited motion and pain motion in each knee. He did not have tenderness or pain to palpation of the joint line or soft tissue of either knee. He had full strength in flexion and extension, at 5/5, in each knee. Testing for ligamentous stability was normal in all planes in each knee and there was no evidence or history of recurrent patellar subluxation or dislocation. He did not use any assistive device as a normal mode of locomotion. Imaging had revealed arthritis in each knee. Veteran’s knee disorders did not impact his ability to work. The examiner opined that the Veteran had left knee tendonitis with minimal functional limitations. It was also opined that the Veteran had postservice SP right knee torn menisci with minimal functional limitations which was less likely as not proximately caused by, the result of, or aggravated by his service-connected left knee disorder. In stating the rationale, the examiner cited to many service treatment records (STRs) and postservice clinical records and noted that in 2005 it was reported that the Veteran had right knee pain without a history of known trauma. The Veteran had no history of physician visits or orthopedic consults for left knee disability after service, which indicated that he did not have a severe chronic left knee disorder. VA clinical notes indicated that the Veteran had been employed performing hard labor of daily digging holes which had a significant risk for repetitive knee trauma. The preponderance of the evidence did not support a nexus for injury to contralateral joints. The examiner noted that during the stance phase of walking, a person placed no more weight on a knee regardless of whether the contralateral knee was normal or painful; instead, the stance phase was shortened in the painful knee and prolonged in the painless knee, and this did not create injury to the painless or contralateral knee. Thus, the Veteran’s right knee torn meniscus, SP meniscectomy, was less likely than not proximately caused by, the result of, or aggravated by his service-connected left knee disorder. On VA respiratory examination in August 2012 the Veteran reported that during service he had had a cyst removed from the inside of his chest wall. After service he began having sensitivity and soreness in that area. He had had asthma as a child but had not had a problem with it as an adult. The examiner noted that a February 2012 chest X-ray was normal and an August 2012 chest X-ray revealed a questionable right 8th rib fracture. August 2012 pulmonary function testing revealed no obstruction or restriction. The diagnosis was asthma, pre-existed military service and without functional limitations. There were no objective findings to support a diagnosis of chronic obstructive pulmonary disease (COPD). The examiner opined that the Veteran had some obstructive lung disease, probably a combination of smoking and his asthmatic condition and less likely than not secondary to his SP incision and drainage of a pleural abscess with partial rib removal. On VA respiratory examination in August 2012 the Veteran’s postoperative and linear thoracotomy scar, for inservice incision and drainage of a pleural abscess, was on the left side of his chest, directly inferior and central to the left axilla, at the T5-6 level. It was 14.5 cms. by .3 cms. The examiner stated that there were no other pertinent physical findings, complications, conditions, signs or symptoms, e.g., muscle or nerve damage, associated with the scar. The scar did not impact the Veteran’s ability to work. The diagnosis was residual scar SP incision and drainage of pleural abscess with partial rib removal with no disfigurement and no dysfunction. In VA Form 21-4138, Statement in Support of Claim, in December 2012 the Veteran reported that he had headaches which began in approximately 1983. In another VA Form 21-4138 of that same date he reported that following inservice surgery on his chest wall in about 1984 he had sensitivity in the surgical area, and occasionally accompanied by uncontrollable twitches. He also reported having erectile dysfunction, difficulty sleeping, and occasional numbness of his hands and arms. The Veteran was afforded several VA examinations on December 24, 2012, at which time the examiner reviewed the claim file. The examiner reported that the Veteran’s skin was warm and dry, with good skin color and normal turgor and without ecchymosis, jaundice or breakdown. His posture and gait were normal, and he did not need an assistive device for ambulation. There was no muscle atrophy or loss of muscle tone, and strength testing was normal. He had callus formation of both feet with metatarsalgia on palpation of the calluses at the metatarsal heads. The examiner reported that loss of function due to flare-ups could not be determined without resorting to speculation. The diagnoses were: no diagnosis to support complaints claimed as chest nerve damage due to scar tissue from surgery; bilateral development of hallux valgus (bunions) after service with no functional limitations and less likely as not caused by, related to, a result of, or aggravated by military service; no diagnosis to support complaints claimed as rectal bleeding; and bilateral foot calluses/paracaratosis, with no functional limitations, which were at least as likely as not incurred in or aggravated by the callus condition that manifested during service. On peripheral nerve examination in December 2012 it was noted that the Veteran reported having hardly any feeling in the surgical site on his chest since the inservice surgery but he had had twitches. On examination all peripheral nerves of both upper and both lower extremities were normal, all reflexes were normal, all sensations and motor strength of both upper and both lower extremities were normal. His gait was normal. The examiner observed that physical examination findings were not consistent with nerve damage. Rather, the Veteran had full sensation around the surgical site, which had a clearly defined, linear and well healed scar without disruption. The Veteran reported having decreased sensation directly on the surgical scar which was consistent with the expected outcome of fibrous tissue that replaced normal tissue destroyed by the direct surgical trauma, i.e., scar. The Veteran’s subjective symptoms, as he related, were not objectively demonstrated on examination. Despite subjective complaints, there were no objective findings to support a diagnosis for chest nerve damage. The Veteran was already service-connected for the postoperative scar. On VA examination of the Veteran’s feet in December 2012 it was reported that the Veteran’s diagnosis of hallux valgus had been made in February 2012, after his military service. The Veteran reported having had foot problems since service in 1982 and which had progressively worsened. He now wore orthotics, which provided some relief. The examiner reported that the Veteran did not have Morton’s neuroma, metatarsalgia, hallux rigidus, pes cavus, malunion or nonunion of the tarsal bones, or hammer toes. He had hallux valgus and the symptoms were mild, bilaterally. He had not had surgery for the hallux valgus. He did not use an assistive device for locomotion. February 2012 X-rays had confirmed bilateral hallux valgus deformity of the 1st metatarsophalangeal joints, bilaterally. The examiner stated that the foot condition did not impact the Veteran’s ability to work and did not cause functional limitations. It was not caused by, related to, a result of, or aggravated by military service. The rationale was that the record was silent for postservice foot pain and treatment for hallux valgus, bunions, began more than 20 years after service. Thus, the bilateral bunions causing foot pain were less likely as not cause by or related to, a result of, or aggravated by military service. On VA genitourinary examination in December 2012 it was reported that the Veteran did not now have and had never had any condition of the rectum or anus. The Veteran reported having had rectal bleeding during service, and had continued to have rectal bleeding, sometimes seeing blood in his toilet stool. He reported having been given suppositories during service but VA records were negative for any prescribed medications. On physical examination his rectal area was normal and there were no palpable rectal internal hemorrhoids and no blood was present. The examiner stated that the Veteran’s inservice episode of rectal bleeding was an acute episode that resolved with appropriate treatment. The comment by the private physician, Dr. Fry, after service indicated no nexus to the single isolated inservice acute event which was associated with diarrhea and which resolved prior to service separation. The was no evidence of hemorrhoids on the current examination and, despite subjective complaints, there were no objective findings to support a current diagnosis, i.e., there was no diagnosis to support complaints claimed as rectal bleeding. On VA skin examination in December 2012 it was reported that the Veteran had a diagnosis of calluses. He reported having had calluses since he started wearing combat boots in boot camp, which had caused foot problems since then. He had no scarring or systemic manifestations. He had not used oral or topical medications in the past 12 months. He had not had any treatments or procedures other than systemic or topical medications in the past 12 months. He had not had any debilitating episodes in the past 12 months. The examiner stated that the Veteran’s calluses were at least as likely as not incurred in military service but they did not impact his ability to work. On VA male reproductive systems examination in February 2013 it was reported that the Veteran was taking Sildenafil, as needed, for erectile dysfunction. The Veteran reported that his erectile dysfunction began around the mid-1990s, after his military service. It was reported that he had been found to have low testosterone in around 2008, and had then been placed on supplementation. A physical examination was normal. Groin or testicular pain shown in service was not the same as or related to erectile dysfunction diagnosed in around 2008, at the Veteran’s age of 44. Medical literature showed that the majority of all males began to show a decline in the ability to achieve an erection at around the age of 40. The Veteran’s condition was consistent with males in his age category and less likely at not due to military service. The diagnosis was erectile dysfunction, which was less likely at not incurred in, caused by or proximately due to military service or any illness, event or testicular condition during service, and most likely due to natural aging and low testosterone. On VA examination on August 18, 2015, for evaluation of the Veteran’s service-connected calluses his electronic records were reviewed. He worked at General Electric as an electronics technician. It was reported that he had recurrent foot pain due to pes planus which required the use of orthotics. He had callus build-up on the plantar surfaces of both feet, along the area of the 1st metatarsal joints. He removed excess callus tissue himself but denied having any skin breakdown or pressure sores. He had no scarring which was either painful or unstable. On physical examination no callus formation was noted. The disability did not impact his ability to work. The examiner remarked that there was minimal evidence of callus formation on the Veteran’s feet. On VA examination of the Veteran’s knees on September 14, 2015, his electronic records were reviewed. The Veteran reported that since his examination in 2012 he had had increased left knee pain and now used a knee brace. As to functional impairment, he reported that his right knee disability was worse than his left knee disability, and his right knee was now bone-on-bone which prevented him from running. He related having to stand a lot in his job and having difficulty going down stairs. He did not report having flare-ups of his knees. On examination the Veteran had left knee extension was full but flexion was limited to only 120 degrees. No pain was noted on motion or weight-bearing. There was tenderness to palpation of the posterior aspect of the left knee, as well as crepitus. He was able to perform repetitive use testing with at least three repetitions but there was no additional functional loss or limitation of motion after three repetitions. Pain, weakness, fatigability or incoordination did not significantly limit functional ability of the left knee with repeated use over a period of time. Muscle strength was normal in flexion and extension in each knee, and there was no muscle atrophy. On testing, there was no joint instability in either knee, and no history of recurrent effusion. He now constantly used a left knee brace. The diagnoses were left knee tendonitis with minimal functional limitations, and SP arthroscopy for torn meniscus of the right knee with degenerative joint disease (DJD), after service. The examiner opined that the Veteran’s right knee disorder was less likely than not proximately caused by, the result of, or aggravated by his service-connected bilateral callus disorder and/or left knee disorder. The rationale was that the preponderance of medical evidence did not support a nexus for injury to contralateral joints. During the stance phase of walking, an individual placed no more weight on a knee regardless of whether the contralateral (opposite) knee was normal or painful; instead the stance phase was shortened in the painful knee and prolonged in the painless knee. This did not create injury to the painless or contralateral knee. The Veteran's right knee torn meniscus and arthritis (DJD) was less likely than not caused by or related to the service-connected left knee condition or bilateral callus. There was no medical nexus because although an abnormal gait might cause some temporary pain in the contralateral knee, no medical literature was found that confirmed that pain of one knee caused arthritis or meniscus injury in the other knee. Osteoarthritis resulted from a complex interplay of multiple factors, including joint integrity, genetics, local inflammation, mechanical forces, and cellular and biochemical processes. For the majority of patients, osteoarthritis was linked to one or more factors, such as aging, occupation, trauma, and repetitive and small insults over time. These associations were strongest for osteoarthritis of the knee and hand, less strong for the hip. The Veteran's right knee DJD was consistent with natural aging, history of arthroscopic surgery, and active lifestyle. Therefore, Veteran's right knee torn meniscus, s/p meniscectomy with DJD, was less likely than not proximately caused by, the result of, or aggravated by his service connected bilateral callus and/or left knee disorder. As to the claim for rectal bleeding, another VA opinion was requested because it was noted that although a prior examiner stated there was no evidence of a current condition; numerous private and VAMC medical records from at least 2000 to the present show ongoing, intermittent complaints of rectal bleeding with diagnoses of internal hemorrhoids, anal fissure, and mild diverticulosis. For that purpose, on December 3, 2015, the Veteran’s electronic records were reviewed. It was reported that the Veteran’s diagnosis of hemorrhoids had been made in January 2000. He had reported that, off and on, he had had rectal bleeding all his life. He related that past colonoscopies since the 1990s had shown diverticulitis and hemorrhoids. He reported that physicians had stated that his bleeding was probably due to hemorrhoids. He had declined a hemorrhoidectomy, but used suppositories or Preparation H. He denied having abdominal pain or cramping, hematemesis or melena. No actual physical examination was conducted and the clinician stated that an examination was not necessary based on objective colonoscopy findings. The clinician summarized the findings of a review of the Veteran’s STRs, as well as postservice clinical records. Past colonoscopies had revealed internal hemorrhoids and diverticulosis of the sigmoid colon. The diagnoses were internal hemorrhoids, claimed as rectal bleeding, and diverticulosis, asymptomatic, being an incidental finding on colonoscopies. It was opined that it was less likely than not that the Veteran’s internal hemorrhoids were incurred in or caused by the rectal complaints during service. The rationale was that the STRs were silent for the actual presence of internal hemorrhoids. The inservice acute and transient rectal bleeding, associated with infectious diarrhea in March 1989 resolved without residuals. The August 1989 separation examination was silent for rectal bleeding, any gastrointestinal conditions and/or residuals. And clinical examination of the Veteran’s anus/rectum, abdomen/viscera at separation were reported to be normal. Also, the December 1989 VA examination, 2 months after service, was silent for rectal bleeding and any gastrointestinal conditions and/or residuals. That physical examination reported that "Hemorrhoids are not present." Rather, the internal hemorrhoids were acquired and diagnosed in 2000, 11 years after service. Contaminated Water at Camp Lejeune The Veteran has alleged that his claim left hallux valgus with bunion, right hallux valgus with bunion, and claimed headaches, are due to contaminated water at Camp Lejeune. VA has recognized that veterans who served at Camp Lejeune for no less than 30 days, either consecutive or non-consecutive, between August 1, 1953 and December 31, 1987, have potential exposure to contaminants present in the base water supply prior to 1988. Honoring America's Appellants and Caring for Camp Lejeune Families Act of 2012, § 505(a), Pub L. 112-154, 126 Stat. 1165 (August 6, 2012) ((codified as amended at 38 U.S.C. § 5103A(b)(2)(B) (hereinafter "Camp Lejeune Act")). Under this law, certain diseases shall be presumed to be the result of exposure to Camp Lejeune base water and may be service-connected provided additional requirements are satisfied. As amended, 38 C.F.R. §§ 3.307 and 3.309(f) includes eight diseases that are presumed to be the result of exposure to Camp Lejeune base water, which are: adult leukemia, aplastic anemia and other myelodysplastic syndromes, bladder, kidney or liver cancers, multiple myeloma, non-Hodgkin's lymphoma, and Parkinson's disease. For those diseases not presumptively linked to contaminated water, service connection for any disability claimed to have resulted from contaminated water exposure at Camp Lejeune requires sufficient medical evidence that the disability is related to that exposure. That medical evidence will generally come from a competent and qualified medical examiner that provides an opinion establishing a rational nexus or link between the claimed disability and the exposure. Some diseases have been scientifically associated to a greater or lesser extent with exposure to the chemical contaminants in the water at Camp Lejeune, however that does not mean that service connection can automatically be established for a Camp Lejeune Appellant claiming one of these diseases. Competent medical opinion must determine whether it is at least as likely as not that the claimed disease or disability has resulted from the contaminant exposure at Camp Lejeune. Sufficient medical evidence to establish the required nexus may also come from a private physician or other competent private medical authority. In this case, the Veteran did serve at Camp Lejeune and, so, his exposure to contaminated water is conceded. However, neither hallux valgus with bunions, of either foot, nor headaches are diseases associated with inservice exposure to contaminated water at Camp Lejeune. More to the point, there is no medical evidence of any such association and, other than the Veteran’s bare assertion of a relationship, there is no lay evidence of any relationship. Equally important the matter of any relationship between inservice exposure to contaminated water and the subsequent development of any disability other than those for which a presumption has already been established, is a complex medical question which is beyond the competency of any mere layperson, including the Veteran. Thus, in sum, there is no competent evidence establishing a nexus between the Veteran’s exposure to contaminated water at Camp Lejeune and his development of hallux valgus with bunions, of either foot, or headaches. Accordingly, based upon this theory of entitlement, service connection for hallux valgus with bunions, of either foot, and headaches must be denied. Principles of Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a link between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). If a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b). The theory of continuity of symptomatology in service connection claims is limited to the chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Certain chronic disease, such as arthritis, malignant tumors, and other organic diseases of nervous system (i.e., peripheral nerves), which are manifested to a compensable degree within one year of discharge from active duty, shall be presumed to have been incurred in service, even though there is no evidence of such a disease during service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.303(b), 3.307(a)(3), 3.309(a). Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis for (1) a disability that is proximately due to or the result of a service-connected condition; or, (2) any increase in severity of a nonservice-connected disease or injury which is proximately due to or the result of service connection condition, and not due the natural progression of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(a), (b). This theory of entitlement requires evidence of (1) a current disability; (2) a service-connected disability; and (3) a nexus, or link, between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). When all the evidence is assembled, the Board is then responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1, 2. Service connection for left and right hallux valgus with bunion Although the Veteran was treated for calluses of his feet during service, there is nothing in the STRs indicating that the Veteran had hallux valgus or bunions of either foot. He did receive post service treatment in 2011 for a skin disorder of the feet which is not shown to be related to service or to his hallux valgus deformity and bunions of each foot. Rather, the earliest contemporary evidence of hallux valgus or bunions of either foot is many years after separation from his military service. A 2012 VA examiner rendered a negative nexus opinion, and while noting the Veteran’s report of having had problems with his feet since military service, the examiner gave greater probative value to the absence of contemporaneous clinical records documenting hallux valgus or bunions until a point in time many years after service. The mere absence of medical records does not contradict a Veteran's statements about his symptom history. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1331, 1333 (Fed. Cir. 2000). In this case, the Board finds that the Veteran did not experience any symptoms of the claimed condition for approximately 20 years after service, which weighs against the claim. In this case, the Veteran's recent statements reporting a long history of foot symptoms are contradicted by past, and the earliest, medical records which are silent for complaints of such symptoms but which it would be expected would have been recorded. See Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011). "[T]he more contemporaneous the evidence, the greater [the] probative value and credibility than can be attached to that evidence, especially when later-dated testimony [] and statements were generated for pecuniary purposes ... 'memory hinges on recency', earlier statements are generally more trustworthy than later ones." Curry v. Brown, 7 Vet. App. 59, 64 (1994). It was the absence of documentation of hallux valgus and bunions for more than 20 years after service that was a pivotal finding in the negative VA medical opinion in December 2012. Thus, while the Veteran is competent to attest to having foot symptoms during and shortly after service, to be accepted as proof of inservice incurrence, or even continuity of symptomatology, his statements also have to be credible. When weighted against the absence of documented corroboration of his complaints, his more recently related history of continuous foot problems beginning during his military service lack credibility. Accordingly, because the preponderance of the evidence is against the claims, service connection for hallux valgus with bunions of each foot is not warranted. 3. Service connection for headaches In 2012 the Veteran first expressed his belief that he had chronic headaches which originated during active service. However, the earliest contemporary evidence of headaches does not antedate 2009. His recent statements reporting a long history of headaches are contradicted by past, and the earliest, medical records which are silent for complaints of headaches but in which it would be expected such complaints would have been recorded. See Kahana, 24 Vet. App. 440. Thus, while the Veteran is competent to attest to having headaches during and after service, to be accepted as proof of inservice incurrence, or even continuity of symptomatology, his statements also have to be credible. When weighted against the absence of documented corroboration of his complaints, his more recently related history of headaches beginning during his military service lack credibility. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for headaches. 4. Service connection for a disorder manifested by rectal bleeding The Board has considered the Veteran’s reported history of having had, off and on, chronic rectal bleeding all his life. However, the STRs show that he had only a transitory episode of rectal bleeding which was associated with an acute episode of diarrhea. Significantly, a recent VA medical opinion ascribed the Veteran’s post service rectal bleeding to his having internal hemorrhoids. Although there is also post service evidence of diverticulosis, the Veteran has reported that his treating physicians have attributed his rectal bleeding to his hemorrhoids, and not diverticulosis, and this was implicitly the finding of the recent VA examiner that rendered the negative medical nexus opinion. More to the point the most recent opining VA clinician reported that the Veteran’s internal hemorrhoids were of post service origin. In this regard, the clinical history relied upon in rendering the 2015 VA negative nexus opinion was incorrect. Specifically, it was stated that the STRs were negative for hemorrhoids. In fact, in March 1989, during service, the Veteran was found to have a small hemorrhoid. On the other hand, his rectal bleeding at that time was attributed to diarrhea, and not to a hemorrhoid. However, as noted in the negative 2015 nexus opinion report, at the time of a VA examination in December 1989, shortly after his military service, the Veteran was reported not to have any hemorrhoids. It is clear that the December 1989 examination did include a physical examination and did not merely record a negative medical history because that examination also including findings relative to the Veteran’s prostate, which could only have been found upon an actual physical examination. Accordingly, the Board must logically conclude that the small hemorrhoid found in March 1989 was transitory and resolved. There is otherwise nothing which relates the Veteran’s acute inservice episode of a hemorrhoid to his current hemorrhoids and current rectal bleeding. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for rectal bleeding. 5. Service connection for nerve damage of the chest The Veteran is service-connected for a residual scar of the anterior chest, associated with SP incision and drainage of pleural abscess with partial rib removal, rated zero percent (noncompensable) disabling under Diagnostic Code (DC) 7805. He now asserts that he has additional disability from his inservice surgery, and has described this as an occasional twitching and discomfort in the area of the PO scar. This is unrelated to the cyst on the right side of his chest for which he was treated in 2007. Moreover, the recent VA examiner found that the Veteran had no more than the normal impairment of sensation from the residual PO scar itself and, significantly, that he had no additional neurologic disability. The Board finds that the clinical knowledge, training, and education of the examiner is such that the examiner’s opinion has greater probative value than building upon the Veteran’s vague lay assertions of additional disability. Thus, the preponderance of the evidence is against the claim for service connection for nerve damage of the Veteran’s chest. 6. Service connection for erectile dysfunction The STRs show that the Veteran had some genitourinary problems during active service, including treatment on several occasions for transmittable but acute diseases. There is nothing in the record which suggests that such acute infections and difficulties are the cause of any erectile dysfunction, and the Veteran does not contend otherwise. The question of any erectile dysfunction was recently and thoroughly addressed by a VA examiner. In sum, that examiner noted that the Veteran’s diminished libido was simply consistent with the aging process, and for which he was now taking medication. Inasmuch as the diminished libido is no more than part and parcel of the aging process, it cannot be considered to be an acquired disability of service origin. Thus, service connection for erectile dysfunction is not warranted. 7. Service connection for a sleep disorder, claimed as difficulty sleeping During service the Veteran denied having difficulty sleeping. Following his military service, and in more recent years, he had breathing difficulties from sinusitis and rhinitis for which he had surgery in 2005 and he also had heaving snoring. However, both he and his wife denied that he had problems due to sleep apnea. It appears that in more recent years he may also have had difficulty sleeping associated with neurologic symptomatology of his upper extremities. However, he is not service-connected for neurologic disability of his upper extremities. There is otherwise no competent evidence that he has any sleep apnea, and any simple sleeping difficulty is not shown to be of such severity as give rise to a level of a functional impairment which impairs his earning capacity. Accordingly, service connection for a sleep disorder, claimed as difficulty sleeping, is not warranted. 8, 9. Service connection for a disorder of the left and right hands Upon review, the record reflects that during service the Veteran had several acute injuries to both hands and fingers of both hands. In August 1982 he had an electrical shock of his right hand, and in February 1988 it was reported that he had a history of a fracture of the right 5th finger; also in February 1988 he had a laceration of the left palm, in June 1989 he had a laceration of the left 3rd finger. It is clear that he received treatment for these acute injuries but more to the point it is neither contended nor shown that he had any chronic disabling residuals from these injuries, other than his right 5th finger. As to the right 5th finger, the April 2011 neurosurgeon’s report demonstrates that this was from a high school injury and, as such, clearly and unmistakably pre-existed the Veteran’s entrance into active service. However, he had no superimposed injury during service to the right 5th finger and because the STRs are negative for complaints, signs, symptoms, or treatment of disability of the right 5th finger the Board concludes that the pre-existing deformity of the PIP joint of the right 5th finger was not aggravated during service. See generally 38 U.S.C. § 1111; 38 C.F.R. § 3.304; Wagner v. Principi, 370 F.3d 1089, 1097 (Fed. Cir. 2004) and Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). Significantly, the post service evidence shows that in 2011 the Veteran had neurological symptoms in at least the left upper extremity. While that evidence indicates possibly pathology of the median nerve, due to CTS, as well as the ulnar and radial nerves of the left upper extremity, that same evidence indicated that the Veteran had only an approximate one-year history of such symptomatology. In other words, the evidence demonstrates that the neurological symptoms are of post service onset and there is otherwise no persuasive evidence that such neurological symptoms are related to the Veteran’s military service. Accordingly, service connection for disorders of the left hand and the right had is not warranted. 10, 11. Service connection for a disorder of the left and right arms and elbows, claimed as pain Upon review, the post service evidence shows that in 2010 the Veteran had the recent onset of pain of the left elbow down to the hand due to lateral epicondylitis or radial tunnel syndrome, or both. However, the Veteran’s symptoms were specifically noted to be of recent onset, and the clinical history recorded by a private physician indicated that this was due to the Veteran’s physical exertion in his post service employment. While that evidence indicates possible pathology of the median nerve, due to CTS, as well as the ulnar and radial nerves of the left upper extremity, that same evidence indicated that the Veteran had only an approximate one-year history of such symptomatology. In other words, the evidence demonstrates that the neurological symptoms are of post service onset and there is otherwise no persuasive evidence that such neurological symptoms are related to the Veteran’s military service. Accordingly, service connection for disorder of the left arm and elbow and the right arm and elbow is not warranted. 12. Service connection for a right knee disorder, claimed as due to service-connected left knee disability The Veteran is competent attest that he puts greater weight on his right leg due to his service-connected left knee disability. However, to go beyond this and conclude that such weight transfer has caused disability of the right knee is outside of the realm of the competence of a layperson and required that application of medical education, knowledge, and expertise which the Veteran does not possess. Generally see 38 C.F.R. § 3.159(a)(1) and (2) (defining competent medical evidence and competent lay evidence). Here, the only competent medical evidence consists of VA medical opinions in 2012 and 2015. Unfortunately, these opinions are negative for any nexus between the Veteran’s service-connected left knee disability and his claimed right knee disability. Those examinations noted that absence of evidence of treatment of left knee disability for many years after service indicated that it was not of such severity as to contribute to right knee disability. Also, the Veteran’s post service employment was of such a nature as to be likely to place stress on, and so possible injury to, the right knee. It was explained that during the stance phase of walking, an individual placed no more weight on a knee regardless of whether the contralateral (opposite) knee was normal or painful; instead the stance phase was shortened in the painful knee and prolonged in the painless knee. This did not create injury to the painless or contralateral knee. Similarly, although an abnormal gait might cause some temporary pain in the contralateral knee, no medical literature was found that confirmed that pain of one knee caused arthritis or meniscus injury in the other knee. Rather, the most recent VA examiner concluded that the Veteran's right knee torn meniscus and arthritis were less likely than not caused by or related to the service-connected left knee condition or bilateral callus formation, and the right knee DJD was consistent with natural aging, history of arthroscopic surgery, and active lifestyle. Accordingly, service connection for a right knee disorder is not warranted. 13. A rating higher than 10 percent for a left knee disorder When evaluating joint disabilities that are rated based on limitation of motion, consideration is given to functional loss due to pain, weakness, excess fatigability, or incoordination, factors not contemplated in the relevant rating criteria. 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. See id. In evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Read together, DC 5003 and 38 C.F.R. § 4.59 provide that painful motion due to degenerative arthritis that is established by x-ray is deemed to be limitation of motion and warrants the minimum compensable rating for the joint, even if there is no actual limitation of motion. Lichtenfels v. Derwinski; 1 Vet. App. 484, 488 (1991). The provisions of 38 C.F.R. § 4.59 relating to painful motion are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Separate ratings may be assigned for limited knee motion in flexion and in extension, as well as for instability, under Diagnostic Codes (DCs) 5260, 5261, and 5257. VAOPGCPREC 23-97 (Jul. 1, 1997) (a DC need not include an exhaustive list of symptoms) and, additionally a separate compensable rating may be assigned for meniscal pathology under DCs 5258 or 5259. Lyles v. Shulkin, No. 16-0994, slip op. at 10 (U.S. Vet. App. Nov. 29, 2017). Normal range of motion of the knee is from 0 degrees of extension to 140 degrees of flexion. 38 C.F.R. § 4.71, Plate II (2017). Under DC 5257, a 10 percent rating is warranted where there is slight recurrent subluxation or lateral instability, a 20 percent rating is warranted where there is moderate recurrent subluxation or lateral instability, and a 30 percent rating is warranted where there is severe recurrent subluxation or lateral instability. Under DC 5258, a 20 percent rating is warranted for dislocated semilunar cartilage with frequent episodes of "locking," pain, and effusion into the joint. Where there is symptomatic removal of semilunar cartilage, a 10 percent rating is warranted under 38 C.F.R. § 4.71a, DC 5259. Under DC 5260, a noncompensable rating is warranted where knee flexion is limited to 60 degrees, a 10 percent rating is assigned where knee flexion is limited to 45 degrees, a 20 percent rating is warranted where knee flexion is limited to 30 degrees, and a 30 percent rating is assigned where knee flexion is limited to 15 degrees. Under DC 5261, a noncompensable rating is warranted where knee extension is limited to 5 degrees, a 10 percent rating is assigned where knee extension is limited to 10 degrees, a 20 percent rating is warranted with extension is limited to 15 degrees, a 30 percent rating is warranted where extension is limited to 20 degrees, a 40 percent rating is assigned where knee extension is limited to 30 degrees, and a 50 percent rating is warranted for extension limited to 45 degrees. As a preliminary matter, the Board notes that the evidence fails to show that the following diagnostic codes are applicable in the present case: 5055 (knee prosthesis); 5256 (ankylosis of the knee); 5262 (impairment of tibia and fibula); and 5263 (genu recurvatum). In this case, the VA examinations in 2012 and 2015 found no ligamentous instability. However, the Veteran reported in 2015 that his left knee disability had become worse since the 2012 examination, such that he used a knee brace. In this regard, “DC 5257 doesn't speak to the type of evidence required and, thus, objective medical evidence isn't required to establish lateral knee instability under that DC.” English v. Wilkie, No. 17-2083, slip op. at 1 and 2 (U.S. Vet. App. Nov. 1, 2018) (panel decision). Thus, objective medical or clinical evidence of instability, such as examination findings, are not categorically more probative than lay evidence. Further, as with pain, such symptoms as subluxation and instability are subjectively experienced and lay evidence of such symptoms is by its very nature subjective in nature. Perceptions of subjective sensations, e.g., pain, subluxation, instability, may vary significantly from one person to another as can the description of both the actual symptoms and the subjective perception of the function impact of such symptom(s). Pain alone is not measurable by any clinical standard or clinical test and the impact as well as the perception of pain is by its nature subjective and its production of disablement is not capable of accurate measurement. Many disabilities can be productive of pain, and most are productive of pain. While pain can be disabling, and is a consideration for rating purposes in all cases, the very subjectiveness of it is not the best means of determining the overall dysfunction of a disorder, which may well include factors other than pain. Objective clinical tests, being standardized, provide a better means of determining the overall dysfunction due to a disability. Range of motion testing is one such test, and another is testing of range of motion after repetition of motion. Likewise, instability, is capable to objective measurement, in terms of the range of instability or subluxation as measured in millimeters. For example, a proposed regulatory amendment of 38 C.F.R. § 4.71a, DC 5257 intends to consider the degree of joint translation in establishing three grades of subluxation or instability, with Grade I being defined as 0 – 5 millimeters (mms.), Grade 2 being 6 – 10 mms., and Grade 3 being equal to or greater than 11 mms. See 82 Fed. Reg. 35728 (Aug. 1, 2017). In this case, based on the Veteran’s subjective complaint of giving way of the left knee, and his use of a left knee brace for added stability, the Board concludes that he has slight instability which is encompassed in the current 10 percent disability rating. However, given the absence of corroborating clinical findings of virtually any instability the Board must find that the Veteran does not have such instability as to equate with moderate instability. The 2012 and 2015 VA examinations also found that the Veteran had full and painless motion in extension and painless flexion to 120 degrees, both of which are noncompensable. Those examinations did not find that the Veteran had more than minimal functional impairment. Neither examination was conducted during a flare-up. Functional loss, including during flare-ups, can be describe by using findings of any additional limitation of motion after repetitive motion testing. If an examination was not conducted during a flare-up, such additional loss of motion after repetitive motion testing is the closest means of determining additional functional impairment during a flare-up. Here, such repetitive motion testing found no additional limitation of motion after three repetitions of motion. Accordingly, an evaluation in excess of 10 percent for the service-connected left knee disorder is not warranted. 14. An initial compensable rating for bilateral calluses The Veteran’s service-connected calluses have been rated under 38 C.F.R. § 4.118, DC 7806 as dermatitis or eczema. Under 38 C.F.R. § 4.118, DC 7806, for rating dermatitis or eczema, a noncompensable rating is assigned where there is involvement of less than 5 percent of the entire body or less than 5 percent of exposed areas are affected, and no more than topical therapy is required during the past 12-month period. A 10 percent evaluation is warranted when at least 5 percent, but less than 20 percent of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas are affected, or there is intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six (6) weeks during the past 12 months. Higher ratings may also be assigned. Alternatively, disabilities rated under DC 7806 may be rated as disfigurement of the head, fact or neck (7800) or scars (DC’s 7801, 7802, 7803, 7804 or 7805) depending upon the predominant disability. The Veteran's skin involvement is isolated to his feet which are unexposed areas. Thus, DC 7800, disfigurement of the head, face or neck, is not applicable. See Butts v. Brown, 5 Vet. App. 532 (1993). DC 7801 relates to disabilities for scars, other than the head, face, or neck, that are deep and nonlinear, and are evaluated by the measurement of the area of the scar. That DC requires that for a minimum 10 percent rating that the area or areas involved be at least 6 square inches (39 sq. cms.) but less than 12 square inches (77 sq. cms.). DC 7802 pertains to disabilities for scars, other than the head, face, or neck, that are superficial and nonlinear. DC 7802. For a minimum 10 percent rating under DC 7802 there must be an area or areas of involvement of 144 sq. inches (929 sq. cms.). DC 7804 provides for evaluations of unstable or painful scars. One or two scars that are unstable or painful warrant a 10 percent rating. Three or four scars that are unstable or painful warrant a 20 percent rating. Five or more scars that are unstable or painful warrant a 30 percent rating. Finally, DC 7805 provides for a scar to be rated on the limitation of function of the affected part. Notes under 38 C.F.R. § 4.118 provide that a superficial scar is one not associated with underlying soft tissue damage. A deep scar is one associated with underlying soft tissue damage. An unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. There is evidence that the Veteran has porokeratosis. The VA examination in December 2012 rendered a diagnosis of “calluses/paracaratosis” of each foot. Thus, the Board will assume that the Veteran’s calluses and his paracaratosis are both service-connected and impairment of each will be considered for rating purposes. However, the Veteran is not service-connected for bilateral hallux valgus with bunions and the mild symptoms from this which were found on examination in December 2012 will not be considered for rating purposes. In this case, the Veteran’s calluses to neither involve at least 5 percent of the total body surface nor at least 6 square inches. Moreover, while he received private treatment in 2011, he has not had any systemic therapy and the calluses are not painful and do not equate to unstable scars because there is no loss of covering of the skin. Also, the evidence does not demonstrate that the calluses impair function of the Veteran’s feet. Specifically, repeated examinations have shown that there is no impairment of his gait and no assistive device is required for ambulation. A December 2012 VA examiner found that there was no functional limitation and no impact on his ability to work. Although the more recent examination in August 2015 noted that the Veteran removed callus tissue himself, there was no skin breakdown, pressure sores or painful or unstable scarring. In fact, the examiner described the extent of involvement was being minimal and again it was concluded that there was no impact on the Veteran’s ability to work. Accordingly, based upon a preponderance of the evidence the Board concludes that a compensable evaluation for the service-connected bilateral calluses is not warranted. DEBORAH W. SINGLETON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Department of Veterans Affairs