Citation Nr: 18154667 Decision Date: 11/30/18 Archive Date: 11/30/18 DOCKET NO. 16-49 846 DATE: November 30, 2018 ORDER New and material evidence having been received, the previously and finally denied claim for service connection for a right knee disability is reopened; the claim is granted to this extent only. New and material evidence having been received, the previously and finally denied claim for service connection for a left knee disability is reopened; the claim is granted to this extent only. New and material evidence has not been received to reopen the previously and finally denied service connection claim for a right foot disability. New and material evidence has not been received to reopen the previously and finally denied service connection claim for migraine headaches. Service connection for a right knee disability, to include as due to a Gulf War qualifying chronic disability, is denied. Service connection for a left knee disability, to include as due to a Gulf War qualifying chronic disability, is denied. Service connection for a cervical spine disability (claimed as muscle strain), to include as due to a Gulf War qualifying chronic disability, is denied. FINDINGS OF FACT 1. In an August 2007 rating decision, in pertinent part, the Regional Office (RO) denied service connection claims for common tractable migraines, first metatarsophalangeal joint degenerative joint disease, and recurring knee pain of an unspecified knee. The RO notified the Veteran accordingly on August 22, 2007. He did not file a notice of disagreement (NOD) or submit new and material evidence within one year. 2. New and material evidence has been received since the August 2007 rating decision to reopen the previously and finally denied service connection claim for a right knee disability. 3. New and material evidence has been received since the August 2007 rating decision to reopen the previously and finally denied service connection claim for a left knee disability. 4. New and material evidence has not been received since the August 2007 rating decision to reopen the previously and finally denied service connection claim for a right foot disability. 5. New and material evidence has not been received since the August 2007 rating decision to reopen the previously and finally denied service connection claim for migraine headaches. 6. The Veteran’s current right knee disability did not begin during active service, and is not otherwise related to an in-service injury, event, or disease; and his current knee symptoms have been competently attributed to a known diagnosis. 7. The Veteran’s current left knee disability did not begin during active service, and is not otherwise related to an in-service injury, event, or disease; and his current knee symptoms have been competently attributed to the known diagnosis. 8. The Veteran’s current cervical spine disability did not begin during active service, and is not otherwise related to an in-service injury, event, or disease; this disability did not manifest to a compensable degree within one year of service; and his current neck symptoms have been competently attributed to known diagnoses. CONCLUSIONS OF LAW 1. The August 2007 rating decision is final. 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 3.156, 20.302. 2. The criteria for reopening the previously and finally denied service connection claim for a right knee disability have been met. 38 U.S.C. §§ 5103A, 5108; 38 C.F.R. § 3.156. 3. The criteria for reopening the previously and finally denied service connection claim for a left knee disability have been met. 38 U.S.C. §§ 5103A, 5108; 38 C.F.R. § 3.156. 4. The criteria for reopening the previously and finally denied service connection claim for a right foot disability have not been met. 38 U.S.C. §§ 5103A, 5108; 38 C.F.R. § 3.156. 5. The criteria for reopening the previously and finally denied service connection claim for migraine headaches have not been met. 38 U.S.C. §§ 5103A, 5108; 38 C.F.R. § 3.156. 6. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 7. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 8. The criteria for service connection for a cervical spine disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1988 to December 1991. Initially, during the pendency of the present appeal, the Veteran’s comments and submissions have suggested his intent to file other claims. On March 23, 2015, VA received documents from the Veteran discussing his mental health issues, but he had not filed such a claim. While pursuing the claim for service connection for a neck disability, at times the Veteran raised contentions regarding a low back condition. In fact, during the March 28, 2015, VA spine examination, the Veteran made statements implying he wanted to file a petition to reopen the previously denied service connection claim for a back condition. However, the issue of service connection for a low back disability is not presently on appeal. See December 2014 claim form (new claim for service connection for a neck disability claimed as muscle pain; this was only spinal issue raised in this claim presently on appeal); see also April 2015 rating decision on appeal (addressing neck claim). Moreover, effective on and after March 24, 2015, VA updated the regulations concerning the filing of claims. 79 Fed. Reg. 57,660 (Sept. 24, 2014) (codified in 38 C.F.R. Parts 3, 19, and 20 (2015)). In part, the Department replaced the informal/formal claims process with a standardized and more formal process. See 79 Fed. Reg. at 57,663-64; see also 38 C.F.R. § 3.155 (2015). As a result of the rulemaking, a complete claim on an application form is required for all types of claims. 38 C.F.R. § 3.155(d). If the Veteran wishes to file additional claims, such as for mental health issues or to reopen the back condition, he must do so using VA’s standardized claims form. A waiver of initial RO review of additional evidence submitted by the Veteran is automatic in substantive appeals filed after February 2, 2013, unless the claimant or claimant’s representative requests in writing that the Agency of Original Jurisdiction (AOJ) initially review such evidence. 38 U.S.C. § 7105(e). Here, the Veteran filed a substantive appeal in October 2016 and submitted additional, pertinent evidence after the September 2016 Statement of the Case (SOC). Neither he nor his representative requested AOJ review of that evidence in writing. Therefore, the Board may proceed with the decisions below. The Board has thoroughly reviewed all the evidence in the Veteran’s VA files. In every decision, the Board must provide a statement of the reasons or bases for its determination, adequate to enable an appellant to understand the precise basis for the Board’s decision, as well as to facilitate review by the Court. 38 U.S.C. § 7104(d)(1); see Allday v. Brown, 7 Vet. App. 517, 527 (1995). Although the entire record must be reviewed by the Board, the Court has repeatedly found that the Board is not required to discuss, in detail, every piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (rejecting the notion that the Veterans Claims Assistance Act mandates that the Board discuss all evidence). Rather, the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See id. Pertinent regulations for consideration were provided to the Veteran in the September 2016 SOC and will not be repeated here in full. Neither the Veteran nor his representative has raised any duty to notify or duty to assist issues regarding the issues denied herein. 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). Petitions to Reopen In an August 2007 rating decision, in pertinent part, the RO denied service connection claims for common tractable migraines, first metatarsophalangeal joint degenerative joint disease, and recurring knee pain. The RO notified the Veteran accordingly on August 22, 2007. He did not file an NOD or submit new and material evidence within one year, and the 2007 rating decision became final. The preliminary question of whether a previously denied claim should be reopened is a jurisdictional matter that must be addressed before the Board may consider the underlying claim on its merits. Barnett v. Brown, 8 Vet. App. 1, 4 (1995), aff’d, Barnett v. Brown, 83 F.3d 130 (Fed. Cir. 1996). The initial question before the Board, therefore, is whether new and material evidence has been received, regardless of how the RO characterized the issue. New and material evidence need not be received as to each previously unproven element of a claim to justify reopening; the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” Shade v. Shinseki, 24 Vet. App. 110, 117-120 (2010). In determining whether newly-received evidence is new and material, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Newly submitted evidence may be material if it provides a more complete picture of the circumstances surrounding the origin of the Veteran’s disability. See Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998). After a full review of the record, the Board finds that new and material evidence has been received to reopen the previously and finally denied service connection claims for right and left knee disabilities. However, new and material evidence has not been received to reopen the previously and finally denied service connection claims for a right foot disability and headaches. 1. New and material evidence has been received to reopen the previously and finally denied service connection claims for right and left knee disabilities. The August 2007 rating decision’s rationale for denying the original service connection claim for a knee disability (specific knee not clarified) was the lack of a currently diagnosed knee disability. Since then, VA has received competent medical evidence showing a current diagnosis of bilateral knee strain. See March 2015 VA knee examination. As this additional evidence was not previously submitted to agency decision makers and relates to unestablished facts necessary to substantiate the claims, the evidence is new and material. 38 C.F.R. § 3.156. Therefore, the previously and finally denied service connection claims for right and left knee disabilities are reopened; the claims are granted to this extent only. As the RO reopened and adjudicated these claims on the merits, the Board may proceed with the decisions herein. 2. New and material evidence has not been received to reopen the previously and finally denied service connection claim for a right foot disability. In February 2007, the Veteran filed an original service connection claim for foot pain (though he did not specify which foot was the basis of the claim). On the 2007 claim form, he contended that his current foot condition began in 1999 (i.e., years after service), and that he believed this condition was the result of years of running on concrete during service. (Although the February 2007 claim form expressly asked about Gulf War environmental exposures, he did not respond to the question.) The August 2007 rating decision’s rationale for denying this claim was that this condition was neither incurred in nor caused by service. (While the February 2007 claim did not specify which foot was the basis of the claim, the 2007 rating decision expressly adjudicated the issue regarding the right foot.) In December 2014, the Veteran filed the petition to reopen presently on appeal, asserting the new etiology theory that his current foot disability was due to Gulf War environmental exposures. A new etiology theory does not constitute a new claim, but rather is a petition to reopen. Velez v. Shinseki, 23 Vet. App. 199 (2009); Ashford v. Brown, 10 Vet. App. 120, 123 (1997); Roebuck v. Nicholson, 20 Vet. App. 307 (2006). However, additional evidence received in support of the new theory of entitlement may constitute new and material evidence, in which case VA must reopen the claim. Boggs v. Peake, 520 F.3d 1330, 1336-37 (Fed. Cir. 2008). After a full review of the record, the Board finds that VA has not received new and material evidence since the August 2007 rating decision that would warrant reopening the service connection claim for a right foot disability. The Veteran was afforded a VA foot examination in March 2015 in which he denied a history of a right foot injury. The examiner found that his right foot was not currently symptomatic and competently provided a negative nexus opinion, citing the Veteran’s own report of a lack of a history of injury. No findings in the 2015 VA examination (including the Veteran’s presumptively credible lay statements denying a history of a right foot injury) suggest that his current right foot disability was incurred in or related to service in any way. In addition, since the 2007 rating decision, VA has received additional VA outpatient treatment records noting duplicative complaints of chronic right foot pain. However, no VA providers competently suggested that his current right foot disability was incurred in or related to service in any way. Moreover, since the 2007 rating decision, the Veteran has asserted that he believes his current right foot condition is due to exposure to environmental hazards during his verified Southwest Asia service. See December 2014 claim form. His lay statements are presumptively credible for purposes of determining whether to reopen the claim under Justus, supra. However, his lay statements are not presumptively competent. Indeed, as a lay person, he is not competent to assert that his current right foot condition is related to in-service environmental exposures because such etiology opinions require evaluation by a medical professional. In summary, no competent evidence suggesting that the Veteran has a current right foot condition that was incurred in service or is otherwise related to service has been received since the 2007 rating decision. Moreover, the fact that the Veteran served in Southwest Asia during the Persian Gulf War previously was of record at the time of the 2007 rating decision. See, e.g., January 1992 VA dental claim form (indicating DD Form 214 and service treatment records had been received by RO then -- despite DD Form 214 scan date in the electronic claims file of December 2014; DD Form 214 verifies Southwest Asia service from January to April 1991); February 2007 VA compensation claim form (reporting Gulf War service). Thus, any evidence relating to this fact that was received after the 2007 rating decision is duplicative of evidence that was previously of record. The Board recognizes that additional evidence received in support of a new etiology theory may constitute new and material evidence that warrants reopening the claim. Boggs, 520 F.3d at 1336-37. However, this principle does not apply here because VA has not received new and material evidence in support of the Veteran’s new Gulf War environmental hazard theory since the 2007 rating decision for the reasons explained above. In summary, new and material evidence has not been received since the August 2007 rating decision to reopen the previously and finally denied service connection claim for a right foot disability. 38 C.F.R. § 3.156. Therefore, the Board declines to reopen the claim. 3. New and material evidence has not been received to reopen the previously and finally denied service connection claim for migraine headaches. In February 2007, the Veteran filed an original service connection claim for recurring headaches. On the 2007 claim form, he contended that his headaches began during service in January 1991, and that they were the result of a documented, in-service lumbar spinal tap procedure that was conducted to treat spinal meningitis. (As noted above, although the February 2007 claim form expressly asked about Gulf War environmental exposures, he did not respond to the question.) The August 2007 rating decision’s rationale for denying this claim was that this condition was neither incurred in nor caused by service. In December 2014, the Veteran filed the petition to reopen presently on appeal, asserting the new theory that his current headache condition was due to Gulf War environmental hazards. As explained above, a new etiology theory does not constitute a new claim, but rather is a petition to reopen. See Velez, supra; Ashford, supra; Roebuck, supra. However, additional evidence received in support of the new theory of entitlement may constitute new and material evidence, in which case VA must reopen the claim. See Boggs, supra. After a full review of the record, the Board finds that VA has not received any new and material evidence since the August 2007 rating decision that would warrant reopening the service connection claim for headaches. The Veteran was afforded a VA Gulf War and migraine examination in March 2015 in which he reported having headaches since the 2000s (i.e., well after service). The examiner competently opined that his current tension headaches were from a combination of a lack of sleep, stress, and untreated hypertension, none of which are service-connected. No findings in the 2015 VA examination report (including the Veteran’s presumptively credible lay statements regarding his medical history) suggest his current headaches were incurred in or are otherwise related to service. In addition, since the 2007 rating decision, VA has received additional VA outpatient treatment records referencing headache complaints and treatment. However, no VA providers suggested that his current headaches were incurred in or related to service in any way. To the contrary, at least one VA provider competently suggested that his current headaches were related to his poorly managed hypertension, which is not service-connected. See April 2015 VA primary care note (regarding assessment and treatment plan for headaches, concluding that he “needs to get BP [blood pressure] under control”). Some VA outpatient treatment records received since the 2007 rating decision note the Veteran’s reports of headaches since 1991, when he was diagnosed and treated for meningitis during service. However, such lay statements suggesting in-service headache symptoms and continuous symptoms since service are duplicative of lay statements and contentions that previously were of record at the time of the 2007 rating decision. See February 2007 claim form (noting Veteran’s contention that headaches began in January 1991 and were the result of in-service spinal tap treatment for meningitis); see also June 2007 VA headache examination (same). Moreover, since the 2007 rating decision, the Veteran has asserted that he believes his current headaches are due to exposure to Gulf War environmental hazards during his verified Southwest Asia service. See December 2014 claim form. As discussed above regarding the right foot claim, such lay statements are presumptively credible for purposes of determining whether to reopen the claim under Justus, supra. However, they are not presumptively competent. Indeed, as a lay person, he is not competent to assert that his current headaches are related to in-service environmental exposures because etiology opinions on such neurological issues require evaluation by a medical professional. In addition, as explained above regarding the petition to reopen the right foot claim, the fact that the Veteran served in Southwest Asia during the Persian Gulf War previously was of record at the time of the 2007 rating decision. Thus, any evidence received after the 2007 rating decision relating to this fact is duplicative. The Board recognizes that evidence received in support of a new etiology theory may constitute new and material evidence that warrants reopening the claim. Boggs, 520 F.3d at 1336-37. However, that principle does not apply here because VA has not received new and material evidence in support of the Veteran’s new Gulf War environmental hazard theory since the 2007 rating decision for the reasons explained above. In summary, the Board finds that new and material evidence has not been received since the August 2007 rating decision to reopen the previously and finally denied service connection claim for migraine headaches. 38 C.F.R. § 3.156. Therefore, the Board declines to reopen the claim. Service Connection The service connection claims for a right knee disability, a left knee disability, and a cervical spine disability are denied. 1. Service connection for a right knee disability and a left knee disability are denied. The Veteran seeks service connection for right and left knee disabilities. He contends that his current knee disabilities are due to years of running on concrete during service. Alternatively, he contends that these conditions are due to environmental exposures during his verified Gulf War service in Southwest Asia. The Board concedes the presence of current right and left knee disabilities. See March 2015 VA examination (diagnosing bilateral knee strain). However, after a full review of the record, both claims must be denied because the evidence does not support a finding that his current right and left knee disabilities were incurred in or are otherwise related to service. Initially, to the extent that the Veteran and his representative contend he is entitled to presumptive service connection under the Gulf War presumption for qualifying chronic disabilities, the Board rejects that contention. Those presumptive provisions do not apply because his current bilateral knee symptoms have been competently attributed to the known clinical diagnosis of bilateral knee strain. See March 2015 VA examination. Nor is the Veteran entitled to service connection on a presumptive basis under the chronic disease provisions. As knee strain is not listed as a “chronic disease” under 38 C.F.R. § 3.309(a), the chronic disease presumptive provisions do not apply. For the same reason, the provisions governing service connection based on continuity of symptomatology do not apply. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (holding that the “chronic” in service and “continuous” post-service symptom presumptive provisions of 38 C.F.R. § 3.303(b) only apply to “chronic” diseases listed under § 3.309(a)). In addition, the Veteran is not entitled to service connection for his right and left knee disabilities on a direct basis. There is no competent evidence of record showing that these disabilities were incurred in or are otherwise related to service. The Veteran’s service treatment records are negative for references to right or left knee complaints, diagnoses, or treatment. To the contrary, his March 1989 periodic examination and November 1991 separation examination found his lower extremities and musculoskeletal system were normal. Moreover, he affirmatively denied having a “trick” or locked knee, arthritis, and swollen or painful joints in his November 1991 separation report of medical history. The Veteran was afforded a VA knee examination in March 2015 in which he was diagnosed with bilateral knee strain. The 2015 VA knee examiner did not suggest, and the Veteran did not assert during the examination, that his current bilateral knee condition was related to service in any way. Notably, the Veteran denied any history of a bilateral knee injury, even though it clearly was in his interest to do so; indeed, the express purpose of the VA examination was to assist him in substantiating his service connection claims. The Board recognizes that various VA outpatient treatment records describe the Veteran as a combat Veteran or note that he described himself as such. See, e.g., December 2014 VA PTSD consult. However, the Board finds that the combat presumption does not apply here to establish in-service right or left knee injuries. Notably, he does not appear to contend that his current right or left knee disabilities arose from any event or injury during combat for which there are missing, contemporaneous service treatment records. Nor does the evidence show that he engaged in combat with the enemy. See Moran v. Peake, 525 F.3d 1157 (Fed. Cir. 2008) (holding that combat presumption provisions require veteran to have personally participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality). He undisputedly served in Southwest Asia during the Persian Gulf War as a communications systems operator. See DD Form 214. However, service in a combat zone alone, or a veteran’s MOS, without more, do not automatically trigger the combat presumption. Also, even assuming the combat presumption applied here, the presumption does not relieve a veteran of the need to establish competent medical evidence of a nexus between the current disability service. Clyburn v. West, 12 Vet. App. 296 (1999). As discussed below, the nexus element is unsatisfied here. There is no competent medical evidence of record suggesting that the Veteran’s current bilateral knee strain, first diagnosed more than two decades after service, may be related to service in any way. His VA outpatient treatment records reference chronic knee pain, and he reported to at least one VA provider that he believes his current joint issues are related to service. See December 2014 VA social work note. However, no VA medical providers competently suggested that his current bilateral knee strain was related to any event or injury during service, to include running on concrete or Gulf War environmental hazards. The Board recognizes the Veteran’s contentions that his current bilateral knee strain may be related to service, including running on concrete or Gulf War environmental exposures. As a lay person, he is competent to report in-service events he observed and knee symptoms such as pain. However, he is not competent to conclude that his current right and left knee disabilities are related to service because such orthopedic issues are not amenable to lay opinions on etiology. Therefore, his lay statements are insufficient to establish service connection. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In conclusion, the claims for service connection for a right knee disability and a left knee disability are denied. As the preponderance of the evidence is against these claims, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 2. Service connection for a cervical spine disability is denied. The Veteran seeks service connection for a cervical spine (neck) condition. He primarily contends that his current neck disability is due to environmental exposures during his verified Gulf War service in Southwest Asia. The Board concedes the presence of current neck disabilities, to include degenerative changes and cervicalgia. See April 2018 VA primary care note; see also May 2018 VA treatment records and imaging report. However, after a full review of the record, the claim must be denied because the evidence does not support a finding that the Veteran’s current neck condition was incurred in or is otherwise related to service. Initially, to the extent that the Veteran and his representative contend he is entitled to presumptive service connection under the Gulf War presumption for qualifying chronic disabilities, the Board rejects that contention. Those presumptive provisions do not apply because his current neck symptoms have been competently attributed to the known clinical diagnosis of cervical spine degenerative changes. See April and May 2018 VA treatment records. Nor is the Veteran entitled to service connection on a presumptive basis under the chronic disease provisions. There is no competent medical evidence of record that chronic cervical spine degenerative changes or arthritis manifested during active service. Moreover, his November 1991 separation examination report found his spine was normal, and an October 1991 ETS radiologic consult found no radiologic evidence of any significant abnormality. In addition, there is no competent medical evidence of record that chronic cervical spine degenerative changes or arthritis manifested to a compensable degree within one year of service. In addition, the evidence does not support a finding of continuous neck symptoms since service. The Veteran reported recurrent back pain in his November 1991 separation report of medical history. He explained that this complaint referred to his documented back complaints after in-service treatment of spinal meningitis. However, service treatment records from early 1991 show that after a January 1991 procedure to treat his meningitis, he specifically complained of low back pain status post “LP,” i.e., lumbar puncture, as opposed to neck pain. Even assuming for the sake of argument that his reports of recurrent back pain at separation encompassed neck complaints as well, a finding of continuity of neck symptoms since service still would be unwarranted. Indeed, after his 1991 separation from service, his next documented report of neck issues was not until he filed his original service connection claim for a neck disability in December 2014, more than two decades after service. Notably, he did not report neck complaints during at least one prior medical encounter when he reported other spinal issues. See June 2007 VA spine examination (noting complaints of low and mid-back issues only). Had he indeed had neck symptoms since service, it is reasonable to expect that he would have reported it during the June 2007 VA spine examination or at some other time during the pendency of the 2007 lumbar spine claim. The fact that he did not weighs against a finding of continuous neck symptoms since service. In summary, the Board finds that any contentions of continuity of neck symptoms since service are not credible. In summary, the weight of the evidence does not show that the Veteran’s current neck degenerative changes began in service or manifested within one year of service; nor does it support a finding of continuity of symptomatology since service. Service connection is therefore unwarranted on a presumptive basis. 38 C.F.R. §§ 3.303(b), 3.307, 3.309. Nor is the Veteran entitled to service connection for a neck condition on a direct basis because the evidence of record does not show that his current neck condition was incurred in or is otherwise related to service. The Veteran’s service treatment records include at least one reference to acute and transitory neck complaints. See January 1991 hospital discharge note (summarizing hospital admission and treatment for viral meningitis; noting he went to emergency room with complaints of general malaise and neck stiffness). However, his service treatment records do not suggest that this isolated complaint of neck stiffness was a possible sign or symptom of a chronic neck disability such as arthritis. To the contrary, his November 1991 separation examination from a few months later affirmatively found his spine was normal. Also, as discussed above, his report of recurrent back pain in his November 1991 separation report of medical history expressly referred to documented, in-service complaints and treatment of lumbar spine pain, as opposed to neck pain. The Board recognizes that various VA outpatient treatment records describe the Veteran as a combat Veteran, or note that he described himself as such. See, e.g., December 2014 VA PTSD consult. However, the Board finds that the combat presumption does not apply here to establish an in-service neck injury. Notably, he does not appear to contend that his current neck disability arose from any event or injury during combat for which there are missing, contemporaneous service treatment records. Moreover, the evidence does not show that he engaged in combat with the enemy. See Moran, supra. He undisputedly served in Southwest Asia during the Persian Gulf War as a communications systems operator. See DD Form 214. However, as explained above, service in a combat zone alone, or a veteran’s MOS, without more, do not automatically trigger the combat presumption. Moreover, even assuming the combat presumption applied here, the presumption does not relieve a veteran of the need to establish competent medical evidence of a nexus between the current disability service. See Clyburn, supra. The nexus element is unsatisfied here as discussed below. There is no competent medical evidence of record suggesting that the Veteran’s current neck degenerative changes, first diagnosed more than two decades after service, may be related to service in any way, including the acute in-service neck complaints noted above, or Gulf War environmental exposures during his verified Southwest Asia service. The Board recognizes the Veteran’s and his representative’s contention that his current neck condition may be related to Gulf War environmental hazards. As a lay person, he is competent to report in-service events he observed and symptoms such as pain. However, he is not competent to conclude that his current neck degenerative changes are related to service because such orthopedic issues are not amenable to lay opinions on etiology. Therefore, his lay statements are insufficient to establish service connection. See Jandreau, supra. In conclusion, service connection for a neck disability is denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Janofsky, Associate Counsel