Citation Nr: 1806594 Decision Date: 02/01/18 Archive Date: 02/14/18 DOCKET NO. 15-37 988 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for bilateral shoulder disorder. 2. Entitlement to service connection for a cervical spine disorder. 3. Entitlement to service connection for a bilateral hip disorder. 4. Entitlement to service connection for a knee disorder. 5. Entitlement to service connection for an ankle disorder, 6. Entitlement to service connection for a bilateral foot disorder. 7. Entitlement to service connection for bilateral hearing loss. 8. Entitlement to service connection for tinnitus. 9. Entitlement to service connection for gastroesophageal reflux disease (GERD). 10. Entitlement to service connection for peptic ulcer disease (PUD). 11. Whether new and material evidence has been received to reopen a claim for entitlement to service connection for a lumbar spine disorder. 12. Entitlement to service connection for a lumbar spine disorder. 13. Entitlement to service connection for type 2 diabetes mellitus. 14. Entitlement to service connection for diabetic peripheral neuropathy, upper extremities (UE). 15. Entitlement to service connection for diabetic peripheral neuropathy, lower extremities (LE). 16. Whether new and material evidence has been received to reopen claim for entitlement to service connection for a nervous condition manifested by anxiety neurosis. 17. Entitlement to service connection for an acquired mental disorder other than PTSD, to include a nervous condition manifested by anxiety and major depression. 18. Entitlement to service connection for PTSD. 19. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD W.T. Snyder, Counsel INTRODUCTION The Veteran served on active duty from October 1969 to September 1971. This appeal to the Board of Veterans' Appeals (Board) arose from rating decisions of a Department of Veterans' Affairs (VA) Regional Office (RO). A February 2015 rating decision denied service connection for a bilateral shoulder disorder; and, a May 2016 rating decision denied the other claims, including a determination that new and material evidence was not received to reopen a claim for anxiety neurosis. The Veteran perfected separate appeals of those determinations. The Veteran's claim for service connection for an acquired mental disorder is deemed to encompass all psychiatric diagnoses. Clemons v. Shinseki, 23 Vet. App. 1 (2009). Hence, the Board has styled the issues of the case as reflected on the title page. Further, a February 1972 rating decision denied entitlement to service connection for anxiety neurosis. Hence, that issue is properly styled as shown on the title page. See Boggs v. Peake, 520 F.3d 1330, 1336 (Fed. Cir. 2008); Clemons, 23 Vet. App. at 4-5; Velez v. Shinseki, 23 Vet. App. 199, 203 (2009). A May 2017 Board letter informed the Veteran that his Motion to Advance His Case on the Board's docket was denied for lack of a showing of good cause. (05/09/2017 Correspondence). The Board has reconsidered that ruling a finds good cause to advance this case on the docket due to financial hardship. 38 C.F.R. § 20.900(c) (2017). The issues of entitlement to service connection for a neck disorder, and an acquired mental disorder other than PTSD, to include a nervous condition manifested by anxiety and major depression are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. A February 1972 rating decision denied entitlement to service connection for a nervous condition, including anxiety neurosis, and a back condition. The Veteran did not appeal the decision, nor was additional evidence on the issues received within one year of the decision. 2. The evidence added to the record since the February 1972 rating decision triggers additional assistance to the Veteran. 3. The weight of the evidence is against a finding that a left (major) shoulder disorder had onset in active service or is otherwise causally connected to active service. 4. The weight of the evidence is against a finding that a currently diagnosed right (minor) shoulder disorder, status post-arthroscopy, is causally connected to active service. 5. The weight of the evidence is against a finding that a bilateral hip disorder had onset in active service or is otherwise causally connected to active service. 6. The weight of the evidence is against a finding that a knee disorder had onset in active service or is otherwise causally connected to active service. 7. The weight of the evidence is against a finding that a bilateral ankle disorder had onset in active service or is otherwise causally connected to active service. 8. The weight of the evidence is against a finding that a bilateral foot disorder had onset in active service or is otherwise causally connected to active service. 9. The evidence of record does not show a right ear hearing loss disability as defined for VA compensation purposes; the weight of the evidence is against a finding that a current left ear hearing loss disability had onset in active service or is otherwise causally connected to active service. 10. The weight of the evidence is against a finding that tinnitus had onset in active service or is otherwise causally connected to active service. 11. The weight of the evidence is against a finding that GERD had onset in active service or is otherwise causally connected to active service. 12. The weight of the evidence is against a finding that PUD had onset in active service or is otherwise causally connected to active service. 13. The weight of the evidence is against a finding that a type 2 diabetes mellitus had onset in active service or is otherwise causally connected to active service. 14. The weight of the evidence is against a finding that diabetic peripheral neuropathy, UEs, had onset in active service or is otherwise causally connected to active service. 15. The weight of the evidence is against a finding that diabetic peripheral neuropathy, LEs, had onset in active service or is otherwise causally connected to active service. 16. The weight of the evidence is against a finding of a confirmed diagnosis of PTSD. 17. Service-connected disabilities do not preclude the Veteran from obtaining and maintaining substantially gainful employment. CONCLUSIONS OF LAW 1. The February 1972 rating decision that denied entitlement to service connection for a nervous condition manifested by anxiety neurosis is final. 38 U.S.C. § 7105 (2012); 38 C.F.R. § 3.156(b), 20.302 (2017). 2. New and material evidence to reopen a claim of entitlement to service connection for a nervous condition manifested by anxiety neurosis has been received, and the petition to reopen is granted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 3. The February 1972 rating decision that denied entitlement to service connection for a low back is final. 38 U.S.C. § 7105; 38 C.F.R. § 3.156(b), 20.302. 4. New and material evidence to reopen a claim of entitlement to service connection for a low back disorder has been received, and the petition to reopen is granted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 5. The requirements for entitlement to service connection for a left (major) shoulder disorder are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 6. The requirements for entitlement to service connection for a right (minor) shoulder disorder, status post-arthroscopy, are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 7. The requirements for entitlement to service connection for a bilateral hip disorder are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 8. The requirements for entitlement to service connection for a knee disorder are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 9. The requirements for entitlement to service connection for a bilateral ankle disorder are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 10. The requirements for entitlement to service connection for a bilateral foot disorder are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 11. The requirements for entitlement to service connection for bilateral hearing loss are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307(a), 3.309(a), 3.385. 12. The requirements for entitlement to service connection for tinnitus are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307(a), 3.309(a). 13. The requirements for entitlement to service connection for GERD are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 14. The requirements for entitlement to service connection for PUD are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 15. The requirements for entitlement to service connection for lumbar spine disorder are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307(a), 3.309(a). 16. The requirements for entitlement to service connection for type 2 diabetes mellitus are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307(a), 3.309(a). 17. The requirements for entitlement to service connection for diabetic neuropathy, UEs, are not met. 38 U.S.C. §§ 1101, 1110, 1112, 107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307(a), 3.309(a), 3.310. 18. The requirements for entitlement to service connection for diabetic neuropathy, LEs, are not met. 38 U.S.C. §§ 1101, 1110, 1112, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307(a), 3.309(a), 3.310. 19. The requirements for entitlement to service connection for PTSD are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304(f). 20. The requirements for a TDIU are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.159, 3.340, 3.341, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist Prior to issuance of the February 2015 and May 2016 rating decisions, via letters dated in November 2014 and October 2016, VA provided the Veteran with notice for his initial claims and claims based on secondary service connection. The Veteran's other claims were adjudicated under the Fully Developed (FDC) Claims Process. Under this framework, a claim is submitted in a "fully developed" status, limiting the need for further development of the claim by VA. When filing a fully developed claim, a Veteran is to submit all evidence relevant and pertinent to his claim other than service treatment records and treatment records from VA medical centers, which will be obtained by the VA. Under certain circumstances, additional development may still be required prior to the adjudication of the claim, such as obtaining additional records and providing a VA medical examination to the Veteran. See VA Form 21-526EZ. The notice that accompanies the FDC form informs the Veteran of what evidence is required to substantiate a claim for service connection and of the Veteran's and VA's respective duties for obtaining evidence. The notice also provides information on how VA assigns disability ratings in the event that service connection is established. See id. Additionally, VA has a duty to assist the Veteran in obtaining identified and available evidence needed to substantiate a claim, and as warranted by law, affording VA examinations. See 38 C.F.R. § 3.159(c). In his Notices of Disagreement and Substantive Appeals (VA Form 9s), the Veteran asserted that VA had not assisted him with his claims; specifically, that he was not afforded VA examinations in conjunction with the adjudications. The Board notes that the Veteran was afforded examinations for his right shoulder and low back claims. Otherwise, VA examinations were not conducted in conjunction with the other claims. Additionally, as noted above, the claim was filed under the FDC framework. In any case, VA will provide a medical examination or obtain a medical opinion where there is insufficient competent medical evidence to make a decision on the claim but: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; and, (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with a veteran's service or with another service-connected disability. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). All elements must be met. The Board finds that the RO correctly determined that there was sufficient competent medical evidence to make a decision on the claim. Further, only Element 1 is shown by the evidence. A letter from the Veteran's private physician, Dr. M-Q, notes that there were current diagnoses for the claimed disorders. (11/24/2014 Medical Treatment-Non-Government Facility) Otherwise, the Veteran's service treatment records (STRs) are silent for complaints related to the conditions claimed by the Veteran, and he was assessed as normal at separation. The Board notes that Dr. M-Q opined that all of the claimed disorders were likely due to the Veteran's active service. Nonetheless, he offered no rationale whatsoever for his otherwise conclusory opinion. While acknowledging that the trigger threshold for an examination is low, see McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006), the Board finds that, in light of the compelling evidence of the lack of an in-service event, and the patent conclusory nature of Dr. M-Q's opinion, the Board finds that the low threshold for an examination was not triggered. See Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed. Cir. 2010); Waters v. Shinseki, 601 F.3d 1274 (Fed Cir. 2010). Further, regarding records, the Veteran's STRs, non-VA, and VA treatment records, including the VA examination reports are in the claims file. VA asked the Social Security Administration for the records related to the grant of disability benefits administered by that agency and was informed that all related records were destroyed. (12/08/2015 SSI/SSA) Neither the Veteran nor his representative has asserted that there are additional records to obtain. As such, the Board will proceed to the merits of the appeal. Applicable Legal Requirements Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v.Brown, 6 Vet. App. 465, 469-70 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). In relevant part, 38 U.S.C. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Board must fully consider the lay evidence of record. Davidson, 581 F.3d at 1316. A layperson is competent to report on the onset of disability and, when applicable, continuity of his or her current symptomatology. See Layno, 6 Vet. App. at 470 (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient to establish a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). The Board is charged with the duty to assess the credibility and weight given to evidence. Wensch v. Principi, 15 Vet. App. 362, 367 (2001). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, and consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) (per curiam). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 57-58 (1990). Background of Back and Mental Claims VA received the Veteran's initial claim for a nervous condition and a back condition in September 1971. An October 1971 VA examination report reflects that the examiner's writing is not entirely legible where the Veteran's description of his back pain is noted. The examiner noted that the Veteran reported that the pain was from the occipital area down. Examination of the musculoskeletal system revealed no cervical limitation of motion, tenderness, spasms, or pain radiating to any area. The examiner noted that there were no physical pathological findings on examination. (10/27/1971 VA Examination, p. 4) The psychiatric part of the examination report reflects that the Veteran reported that he went to sick call for his nerves, neck pain, heart palpitations, and dyspnea. He complained of hunger, but when he ate, he felt bloated. He also complained of a backache and that he often was depressed. Chest X-ray was read as negative. The examiner noted that the Veteran was underweight, he presented with good hygiene, good gait and posture, and he was quiet and cooperative. No disturbance of thought process was noted. His affect was adequate, but the examiner noted that the Veteran showed an overall anxiety. He was oriented and his memory and judgment were both good. The diagnosis was anxiety neurosis. Id. at 5. The February 1972 rating decision reflects that the rating board noted that the Veteran's April 1968 pre-induction examination report reflected that he had given a history of a nervous disorder, insomnia, excessive worry, and inflamed and painful joints. The examination found no neuropsychiatric disorder. The Veteran reported the same history at the September 1969 Induction examination, and the examiner concurred with the previous assessment. The rating board also noted the Veteran's complaints of back pain on several occasions during active service; and, that at the August 1971 examination for separation, the lumbosacral spine manifested with full range of motion (ROM), and the VA examination was negative. The rating board also determined that the Veteran's pre-service mental symptoms were not aggravated by his active service. (02/18/1972 Rating Decision) A March 1972 RO letter informed the Veteran of the decision and of his right to appeal. He did not appeal the decision, nor did VA receive any relevant new and material evidence on the issue within one year of the decision. Hence, it became final. VA received the Veteran's application to reopen the claims in November 2014. (11/24/2014 VA Form 21-4138) New and Material Evidence When a claim is disallowed and becomes final, the claim will not be reopened except as provided by applicable regulation. If new and material evidence is presented or secured with respect to a claim that has been disallowed the Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). "New" evidence means more than evidence that has not previously been included in the claims folder. The evidence, even if new, must be material, in that it is evidence not previously of record that relates to an unestablished fact necessary to establish the claim, and which by itself or in connection with evidence previously assembled raises a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The standard of whether new and material evidence raises a reasonable possibility of substantiating a claim is a "low threshold." See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied, but instead should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. Id. at 118. For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Discussion The May 2016 rating decision reflects that the RO adjudicated the low back claim as a new claim instead of on the basis of new and material evidence. In light of the February 1972 rating decision, however, the Board still must assess for new and material evidence. The Board notes, as set forth above, that the August 2016 SSOC appears to reflect that the RO determined that new and material evidence to reopen the back was received and reopened the claim and adjudicated it on the merits. The cliam for service connection for a psychiatric disorder, to inlcude anxiety neuros and depression, was not reopened. Nonetheless, the Board has the jurisdictional responsibility to consider whether it was proper to reopen the claims. See Jackson v. Principi, 265 F.3d 1366, 1369 (Fed Cir. 2001); Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Thus, the Board will determine whether new and material evidence has been received and, if so, consider entitlement to service connection on the merits. As noted earlier, the February 1972 rating decision denied the low back claim due to the absence of evidence of a then currently diagnosed disorder. The evidence added to the record since that rating decision includes evidence of current diagnoses of lumbar spondylosis and degenerative disc disease. The Board finds that this evidence is new and material (as it relates to a previously unestablished element) evidence to reopen the claim. 38 C.F.R. § 3.156(a). The May 2016 rating decision reflects that the RO determined that new and material evidence was not received to reopen the claim for anxiety neurosis (claimed as depression). Evidence added to the record since the February 1972 rating decision includes Dr. Q-M's November 2014 letter. He noted that the Veteran's diagnoses included general anxiety disorder and major depressive disorder. He also opined that they most likely were causally connected to the Veteran's active service. (11/24/2014 Medical Treatment-Non-Government Facility) For new and material evidence purposes, his opinion is not tested for credibility or weight. Hence, the Board finds that as this evidence has been added since the last final denail it is new and material (as, again, it relates to a previously unestablished element) evidence has been received to reopen the mental disorder claim as well. 38 C.F.R. § 3.156(a). The RO fully developed the low back claim, to include addressing it on the merits, so there is not prejudcie in the Board addressing it on the merits later in this decision. This is not the case with the acquired mental disorder other than PTSD claim. It is discussed further in the remand part of the decision below. Service Connection The general requirements for service connection set forth earlier are incorporated here by reference. Further, arthritis is presumed to have been incurred in service if manifested to a compensable degree within one year of separation from service. This presumption applies to veterans who have served 90 days or more of active service during a war period or after December 31, 1946. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza elements in a claim involving a listed chronic disease is through a demonstration of continuity of symptomatology. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a chronic disease was "noted" during service or within the applicable presumptive period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Walker v. Shinseki, 708 F.3d 1331, 1336-38 (Fed. Cir. 2013); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Spine and Shoulders As noted, the Veteran reported a pre-service history of painful joints at both his Pre-Induction and Induction examinations. (11/21/2017 Correspondence, p. 24, 27 [Translation]) STRs dated in November 1970 note the Veteran's complaints of neck and back pain. A February 1971 entry notes complaints of pain in the back of the neck. Examination revealed full ROM and slightly tight muscles. Neurological examination was normal, and X-rays taken in 1970 were noted to have been uncertain. In March 1971, he complained of back and shoulder pain. Physical examination revealed cervical vertebral tenderness on palpation and on extension; and, muscle spasm at the paravertebral area of the lumbar spine. His treatment plan included no physical training, and no lifting of more than five pounds. In April 1971, the Veteran complained of recurrent lumbar and cervical pain after the strain of heavy exercise times many months. He reported that he initially hurt his back in high school secondary to a fall. Physical examination revealed full ROM of the cervical and lumbar spine, no spasms, and mildly tight paraspinal muscles. The assessment was recurrent lumbar strain, and he was referred for a neurological consult. The Neurological Consult notes that the Veteran reported a five-year history of cervical and lumbar pain without radiation in any direction. Examination revealed no positive neurological findings, X-rays were read as within normal limits. The neurologist recommended an orthopedic consult. The June 1971 Orthopedic Consult notes that the Veteran reported chronic low back pain and cervical pain since high school. A civilian doctor believed it was related to nervous tension, with which the Veteran agreed. The consult noted the negative neurological workup, and that X-rays were within normal limits. The X-ray examination report also noted that a questionable lucent area shown on a 1970 X-ray had been ruled out on a later film. The orthopedic examination resulted in no physical findings. The orthopedist diagnosed chronic cervical and back pain, mild to moderate, EPTS [existed prior to service], orthopedically cleared for separation. (12/16/2014 STR-Medical, p. 10, 17, 19-21) STRs dated in July 1971 note the Veteran's complaints of a pulled muscle in his right shoulder and he wanted it checked out. The medical officer noted that the Veteran was swimming the day before and injured the right trapezius. The examiner noted that there was pain and spasm at that area. He was treated with heat, aspirin, and excused from heavy lifting. Id., p. 30 The June 1971 Report of Medical Examination For Separation reflects that the Veteran's UEs and spine were assessed as normal. Id., p. 5. In August 1971, just prior to his actual separation, the Veteran certified that there had not been any changes in his health since his physical examination. Id., p. 7. He was deemed physically fit for separation. The February 2015 VA shoulder examination report (02/12/2015 C&P Exam) reflects that the examiner conducted a review of the Veteran's electronic records, including the claims file, as part of the examination. The examiner noted diagnoses of record of bilateral rotator cuff tendonitis in 2012; and, bilateral glenohumeral joint osteoarthritis shown on X-rays in December 2014. The Veteran reported complaints of constant bilateral shoulder pain which was worse on overhead activities, and during cold or rainy weather. He underwent an arthroscopy of the right shoulder in August 2007 due to severe humeral head chondromalacia. The examiner opined that it was not at least as likely as not that either shoulder disorder had onset in active service or was otherwise causally connected to active service. The examiner opined that the 1971 in-service right shoulder spasm was acute and transitory. The examiner noted further that both the private and VA records were silent within two to three years after service for the claimed conditions. The February 2016 examination report (02/19/2016 C&P Exam, 6th Entry) reflects that the examiner conducted a review of the Veteran's electronic records as part of the examination. The Veteran reported that he started having low back pain at age 33. He described the pain as severe and of a stabbing nature, and it was located at the mid- and low back area. The examiner noted diagnoses of record of lumbar spondylosis shown on X-rays in 2000, id., p. 10, and lumbar degenerative disc disease shown on MRI examination in 2015. Id., p. 8-9. The examiner opined that it was not at least as likely as not that the Veteran's currently diagnosed low back disorder is causally connected to the Veteran's active service, to include the complaints noted in the STRs. The examiner noted that the absence of positive orthopedic findings at the August 1971 examination; that the Veteran was cleared for separation; and, that his medical records noted diagnoses of his currently diagnosed disorders in 2000 and 2015, several years after his active service. The examiner opined that the Veteran's current low back disorders are due to normal progression of the aging process. (02/19/2016 C&P Exam, 5th Entry, p. 4) The Board finds that the 2015 and 2016 VA examination and opinion weigh against a finding of nexus to the current lumbar spine disorders and the in-service report as recorded in the Veteran's service treatment records. The Board finds this opinions to be deserving much weight as relevant facts were considered, a physical examination - to include diagnostic testing was performed/reviewed, and a supporting rationale was supplied. As such, the preponderance of the evidence is against a nexus and service connection is not warranted. Gastrointestinal (GI) Claim The Veteran's April 1968 pre-induction clinical examination revealed a normal G-U system. STRs dated in February 1970 note the Veteran's complaints of stomach and back pain. The examiner entered an assessment of muscle spasms. Treatment included medication and lifting restriction for five days. Approximately a week later, the Veteran complained of an upper respiratory infection and stomach symptoms. He reported central chest pain and a sore throat and mild neck pain x2 days. Examination revealed the chest as clear to auscultation and percussion, and the throat was without exudate [there were other findings which are illegible]. The impression was flu syndrome. In March 1970, the Veteran complained of cold and stomach symptoms. He complained of a cough and a burning in the chest with coughing. Examination revealed the neck as supple, and throat clear. There were coarse breath sounds over the main bronchi but no rales. The assessment was bronchitis. The June 1971 Report of Medical Examination For Separation reflects that the Veteran's abdomen and viscera were assessed as normal. (12/16/2014 STR-Medical, p. 5, 26-27) The October 1971 VA examination report reflects that the Veteran's digestive system was normal. (10/27/1971 VA Examination, p. 3) The RO arranged an examination of the Veteran. The February 2016 examination report reflects that the examiner examined the Veteran in addition to reviewing the Veteran's electronic records. A history of a diagnosis of gastritis in 1968 was noted. The Veteran reported history of bloating, stomach discomfort, and reflux since 1968, which was before his active service. While a history gastris prior to service was noted, the Board finds that such bare history does not rise to clear and unmistable evidence that such pre-existed his active service. As such, he is presumed sound on entrance, acceptance and enrollment for active service. He reported further that his occasional symptoms improved with medication. (02/19/2016 C&P Exam, 2nd Entry) The examiner opined that it was not at least as likely as not that the Veteran had a current GI disorder that is causally connected to active service. The examiner's rationale was that the Veteran's medical records revealed no GI disorder that had onset during active service. His noted symptoms occurred prior to entry into active service. (Id., 1st Entry) The Board finds that the evidence of record is against the low back claim. As set forth above, the STRs reflect that the primary symptom noted during active service was pain. No underlying disorder was diagnosed, which is required for service connection. Pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). As the VA examiner noted, the Veteran's currently diagnosed disorders were diagnosed several years after his active service. The non-VA related records contain no assessment that they had onset in active service, or are causally connected with active service. See 11/24/2014 Medical Treatment-Non-Government Facility, p.1, 3. The Board acknowledges Dr. Q-M's report. His generic, conclusory nexus opinion, however, contained no rationale or explanation of how the Veteran's low back disorder may be connected to active service. Hence, the Board affords it minimal, if any, weight. Further, Dr. Q-M's opinion simply is outweighed by the other evidence of record. The opposite is true of the VA examiner, who reviewed the claims file, considered the Veteran's lay reported history, and provided a clear rationale for the negative nexus opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Thus, the Board affords it significant weight. There is no evidence that the Veteran's lumbar arthritis manifested within one year of separation from his active service. In the absence of evidence of manifestation in active service or within one year, there is no evidence of a chronic disease at or within one year of active service. Hence, there is no factual basis for service connection on a presumptive basis or under 38 C.F.R. § 3.303(b) or 3.309(a). As noted, he reported at the 2016 examination that his symptoms started at age 33, which would have been in 1981, some 10 years after his active service. He was born in 1948. (See 09/15/1971 VA Form 21-526) The same finding is in order for the arm disorder. The STRs contain no entries related to the Veteran's left shoulder. Left shoulder osteoarthritis was revealed many years after service. There is no evidence that it manifested within one year of service. Both upper extremities were assessed as normal at separation. As discussed above, the VA examiner opined that the in-service right trapezius injury was acute and transitory, which means that it resolved without chronic residuals. 02/12/2015 C&P Exam, 1st Entry) The earlier discussion on the weight to be accorded to Dr. Q-M's opinion is incorporated here by reference. As concerns the Veteran's GI claim, the entries in the STRs do not note diagnosis of a GI disorder. The pre-service examination reports note that the Veteran's doctor attributed his symptoms to his nerves. His digestive system was normal on examination at the October 1971 VA examination. The VA examiner opined that there was no evidence of GI symptoms during the Veteran's active service. Dr. Q-M's November 2014 report notes complaints of nausea, vomiting, flatulence, fatty food intolerance, and epigastric burning type pain. He noted further that a workup was compatible with PUD and GERD. The Veteran's VA outpatient records note GERD among the Veteran's active problems, but they do not indicate onset in active service or any causal connection with active service. Further, in October 2015 they noted that there is no history of PUD. (05/09/2016 LCMD CAPRI, p.62, 113) The Board's prior discussion of Dr. Q-M's opinion is incorporated here by reference. In light of the above, the Board finds that while there is evidence of a currently diagnosed GI disorder, the weight of the evidence is against a finding that a GI disorder had onset in active service or that it is causally connected to active service. 38 C.F.R. § 3.303. Bilateral Hearing Loss and Tinnitus Legal Requirements In addition to the general requirements set forth for service connection earlier, for the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz (Hz) is 40 decibels (db) or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hz are 26 db or greater; or, when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. VA regulations do not preclude service connection for a hearing loss which first met VA's definition of disability after service, provided the evidence of record shows the required nexus with active service. Hensley v. Brown, 5 Vet. App. 155, 159 (1993); see also 38 C.F.R. § 3.303(d). As is the case with arthritis, certain organic diseases of the nervous system are presumed to have been incurred in service if manifested to a compensable degree within one year of separation from service. This presumption applies to veterans who have served 90 days or more of active service during a war period or after December 31, 1946. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). VA deems sensorineural hearing loss and tinnitus as among the organic diseases of the nervous system that are covered. See VA Under Secretary for Health Memorandum (October 1995); see also Fountain v. McDonald, 27 Vet. App. 258, 264, 271 (2015). Discussion A Report of Medical History for the Veteran's physical examination at separation is not of record. The June 1971 Report of Medical Examination For Separation reflects that the Veteran's ears and drums were assessed as normal, and the audiogram reflected no hearing loss. (12/16/2014 STR-Medical, p. 5-6) The RO examination request reflects that the examiner was informed that the Veteran's MOS of combat engineer made it likely that he was exposed to hazardous noise. The February 2016 VA examination report reflects that the Veteran's hearing manifested as follows: HERTZ 500 1000 2000 3000 4000 SPEECH RIGHT 10 15 15 10 25 96% LEFT 10 15 15 25 55 100% The audio examiner noted that the Veteran's hearing was normal at entry into and separation from active service. The audio results reflect that the Veteran's hearing loss did not manifest at the rate that VA deems disabling in the right ear as it did not manifest to the requirements of § 3.385. (02/19/2016 C&P Exam, 4th Entry, p. 2-3) In light of this fact, the Board finds that the preponderance of the evidence is against the claim for the right ear, as there is no current hearing loss disability as defined by VA. 38 C.F.R. §§ 3.303, 3.307(a), 3.309(a). The evidence from the 2016 VA examination shows a current hearing loss disability for VA purposes in the left ear as his hearing was 55 decibels at 4000 Hertz. However, the Board finds that the probative and competent evidence weighs against a nexus. The 2016 VA audiologist provided a negative opinion. In support, the specialist noted that the audiograms from April 1968 and June 1971 each showed normal hearing levels. The examiner coneeded that the Veteran was exposued to high intensity noise levels during his active service, but noted that there was no hearing loss. Additionally, the examiner stated that other factors, such as the normal aging process and health problems, can cause hearing loss. As the examiner was familiar with pertient facts from the Veteran's medical history, to include his in-service noise exposoure and audiograms, the Board places much weight on this piece of evidence. The Board finds that it outweighs the Veteran's lay statements to the contrary, as his is not competent to opine on the etiolgoy of his hearing loss. As concerns the tinnitus, the Board acknowledges that the Veteran is fully competent to report symptoms of tinnitus. 38 C.F.R. § 3.159(a)(2). The Board also acknowledges that there is no clinical or other diagnostic test that confirms or disproves the presence of tinnitus. Notwithstanding the fact that Dr. Q-M included tinnitus among his list of disorders with which the Veteran is diagnosed, the VA examiner noted that the Veteran did not report any complaints of tinnitus. As a result, the examiner opined that there was no tinnitus that is at least as likely as not connected with active service. (02/19/2016 C&P Exam, 3rd Entry, p. 2; 4th Entry p. 5) Hence, the Board also finds that the preponderance of the evidence is against the claim, as there is no current disability. 38 C.F.R. §§ 3.303, 3.307(a), 3.309(a). Type 2 Diabetes Diabetes mellitus is also presumed to have been incurred in service if manifested to a compensable degree within one year of separation from service. This presumption applies to veterans who have served 90 days or more of active service during a war period or after December 31, 1946. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). The Veteran has not asserted any particular basis on which this claim should be granted, except that he is diagnosed with the disease. His only foreign service was in Germany, so he is not presumed to have been exposed to a herbicide agent. See 38 C.F.R. § 3.307(a)(6). The June 1971 Report of Medical Examination For Separation reflects that the Veteran's sugar and albumin were negative, and the October 1971 VA examination report reflects that his endocrine system was normal. (12/16/2014 STR-Medical; 10/27/1971 VA examination) VA outpatient note the maintenance and treatment of the Veteran's diabetes mellitus. There is no notation of report of onset during active service or within one year of separation. (05/09/2016 LCMD CAPRI, p. 8) The earliest prescription on record for his disease is December 2011. Id., p. 174. There simply is no evidence if onset of type 2 diabetes mellitus during active service or within one year of separation. Neither is there any evidence of in-service causality. The Board's early discussion of Dr. Q-M's opinion is incorporated here by reference. Hence, the Board also finds that the preponderance of the evidence, to include the negative separation examination and the 1971 post-service VA examination reports, weighs against the claim on both a presumptive and direct basis. 38 C.F.R. §§ 3.303, 3.307(a), 3.309(a). Neurologic LE Peripheral neuropathy is among the diseases of the CNS that are presumed to have been incurred in service if manifested to a compensable degree within one year of separation from service. This presumption applies to veterans who have served 90 days or more of active service during a war period or after December 31, 1946. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). The Veteran's neurological system was assessed as normal at separation from active service and at the October 1971 VA examination. The evidence of record is against a finding that peripheral neuropathy of the UHE or LE manifested to at least a compensable degree within one year of the Veteran's separation. 38 C.F.R. §§ 3.307(a), 3.309(a). A disability which is proximately due to or the result of a service-connected injury or disease shall be service connected. 38 C.F.R. § 3.310. Further, a disability which is aggravated by a service-connected disorder may be service connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). VA outpatient records note medication for lumbar radiculopathy in June 2001. They also note diabetic neuropathy as of March 2013. (05/09/2016 LCMD CAPRI, p. 7, 196, 350) Private records note EMG results dated in June 2008 that revealed lumbar radiculitis, and NCV results that showed right tarsal tunnel syndrome. Hence, the Board finds that a current disability is shown by the competent evidence of record. However, the Board finds that the evidence of record is against a finding of an in-service incurrence or nexus. The Board notes that the Veteran's service treatment records do not reflect pertinent complaints and/or treatment. As discussed earlier, the Board finds the preponderance of the evidence is against service connection for a lumbar spine disorder and type 2 diabetes mellitus. So, the two potential cause of the current neurological disorders of the LEs have been determined not to be related to service. Hence, the Board finds that the evidence of record is against a finding of service connection on a secondary basis. 38 C.F.R. § 3.310. Hip, Knee, Ankle, and Foot Disorders Neither Dr. Q-M's November 2014 report nor the Veteran's VA outpatient records note currently diagnosed musculoskeletal disorders of the hips, knees, ankles, or feet. VA physical therapy records dated in April 2016 note the Veteran's complaints of bilateral hip pain that started one-year earlier. There also is a notation of complaint of left knee pain. There is no notation of a diagnosed disorder as concerns either joint. (05/09/2016 LCMD CAPRI, p. 3-4) The first requirement for service connection is a currently diagnosed disorder or disease. 38 C.F.R. § 3.303. As earlier noted, pain alone does not satisfy that element. Sanchez-Benitez, 13 Vet. App. at 285. The Board also acknowledges the requirement that a current disability be present is satisfied when a claimant "has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim," McClain v. Nicholson, 21 Vet.App. 319, 321 (2007), or "when the record contains a recent diagnosis of disability prior to ... filing a claim for benefits based on that disability," Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). In this case, the evidence weighs against a finding of currently diagnosed musculoskeletal disorders of the hips, knees, ankles, or feet. Hence, the Board finds that service connection is not warranted for this issues. 38 C.F.R. § 3.303. PTSD In addition to the general requirements for service connection set forth earlier, there are particular requirements in 38 C.F.R. § 3.304(f) for establishing PTSD in addition to those for establishing service connection generally. See Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010) ("Simply put, while section 3.303 mandates that there be a link between a current disability and military service, section 3.304(f) sets forth the evidence necessary, in the context of claims for PTSD disability compensation, to establish that link."). Entitlement to service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and, credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. §§ 3.304(f) and § 4.125 (requiring PTSD diagnoses to conform to the DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS-5 (DSM-5). Dr. Q-M's November 2014 report notes that the Veteran presented with numerous psychiatric symptoms, to include flashbacks of his traumatic experiences during his active service. His diagnoses included PTSD. (05/24/2016 Non-Government Facility, p. 2, 4) Dr. Q-M's report does not list the traumatic experiences to which the noted symptomatology is reportedly connected. The Veteran did not respond to the RO's request for specific information related to claimed stressors. The Form the Veteran returned noted only that his claimed stressors occurred in Germany. (01/21/2016 VA Form 21-0781) In a January 2016 VA Form 21-4138 submitted in Spanish, the Veteran asserted that all went well in Basic and advanced training, and in Germany until he tore a muscle in his shoulder. (Translation, 11/21/2017 Correspondence) The Veteran's MOS was radio operator, and his military personnel records reflect that in Germany he was designated as eligible for hazardous duty pay related to demolition duty. (11/24/2014 MPR, p. 8, 16) The scant information the Veteran provided, however, made no reference to such duty. The RO entered a Formal Finding of Insufficient Information to verify a stressor. (05/10/2016 Web/HTML Documents) The earlier discussion of Dr. Q-M's diagnoses is incorporated here by reference. His report made no reference to DSM, and more importantly, the report did not discuss how the Veteran's claim satisfied the criteria for a valid diagnosis of PTSD. VA outpatient records dated in March 2016 note no diagnosis of PTSD, but do show bipolar disorder, most recent episode, depressed. (05/09/2016 LCMD-CAPRI, p. 10) In light of the above, the Board finds that the preponderance of the evidence is against the presence of a valid diagnosis of PTSD. 38 C.F.R. §§ 3.303, 3.304(f). TDIU In order to establish entitlement to IU, there must be impairment so severe that it is impossible to follow a substantially gainful occupation. See 38 U.S.C.§ 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. In reaching such a determination, the central inquiry is "whether the Veteran's service-connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993) (Emphasis added). For VA purposes, the term "unemployability" is synonymous with an inability to secure and follow a substantially gainful occupation. VAOPGPREC 75-91; 57 Fed. Reg. 2317 (1992). Consideration may be given to the Veteran's level of education, special training, and previous work experience in arriving at a conclusion, but not to his age or to the impairment caused by nonservice-connected disabilities. See 38 C.F.R. §§ 3.341, 4.16, 4.19. VA regulations establish objective and subjective standards for an award of total rating based on unemployability. Currently, service connection is not in effect for any disability. See 05/10/2016 Rating Decision-Codesheet. Hence, there is no factual basis for allowance of a TDIU. 38 C.F.R. §§ 3.340, 3.341. In reaching this decision the Board considered the doctrine of reasonable doubt. As the preponderance of the evidence is against the Veteran's claims, however, the doctrine is not for application. Schoolman v. West, 12 Vet. App. 307, 311 (1999). ORDER Service connection for bilateral shoulder disorder is denied. Service connection for a bilateral hip disorder is denied. Service connection for a knee disorder is denied. Service connection for an ankle disorder is denied, Service connection for a bilateral foot disorder is denied. Service connection for bilateral hearing loss is denied. Service connection for tinnitus is denied. Service connection for GERD is denied. Service connection for PUD is denied. New and material evidence has been received to reopen a claim for entitlement to service connection for a lumbar spine disorder has been received; the appeal is granted solely to that extent. Service connection for a lumbar spine disorder is denied. Service connection for type 2 diabetes mellitus is denied. Service connection for neurologic disorder of the UEs, to include diabetic peripheral neuropathy, is denied. Service connection for neurologic disorder of the LEs, to include neuropathy and radiculoptthy, as due to both type 2 diabetes mellitus and/or lumbar radiculopathy, is denied. New and material evidence has been received to reopen a claim for entitlement to service connection for an acquired mental disorder other than PTSD, to include a nervous condition manifested by anxiety neurosis has been received; the appeal is granted solely to that extent. Service service connection for PTSD is denied. TDIU is denied. REMAND As noted in the decision above, the Board reopened the Veteran's claim for entitlement to service connection for an acquired mental disorder other than PTSD. Now that the claim is reopened, additional assistance in the form of a VA examination has been triggered. See 38 C.F.R. § 3.159(c)(4)(iii). Additionally, the AOJ did not reopen the psychiatric issue in either the rating decision on appeal or the statement of the case. As such, the AOJ needs to review the merits of the underlying issue. See Bernard v. Brown, 4 Vet. App. 384, 394 (1993) (stating that when the Board addresses a question that has not been addressed by the RO, it raises the possibility that the Veteran will be prejudiced by not having been afforded the full benefits of those procedural safeguards). The VA spine examination of record addressed only the Veteran's lumbar spine. No examination was conducted on the Veteran's cervical spine. In light of the Veteran's documented in-service complaints of neck pain, the Board finds that a VA examination was triggered. See McLendon, 20 Vet. App. at 83; 38 C.F.R. § 3.159(c)(4). Accordingly, the case is REMANDED for the following actions: 1. Arragne for a medical nexus review of the claims file by an appropriate examiner. Ask the examiner to opine on whether there is at least a 50-percent probability that the Veteran's currently diagnosed cervical spine disorder(s) is causally connected to the Veteran's active service, to include the instances noted in the STRs? Advise the examiner that a full explanation and rationale must be provided for all opinions rendered. Should the examiner advise that the requested opinion cannot be rendered without an examination, the AOJ shall arrange the examination. 2. Arrange for psychiatric examination of the Veteran by an appropriate mental health examiner. Ask the mental examiner to identify all acquired mental disorders manifested and to opine whether there is at least a 50-percent probability that any or all acquired mental disorders is causally connected to the Veteran's active service. Advise the examiner that a full explanation and rationale must be provided for all opinions rendered. 3. After the above is complete, re-adjudicate the issues on appeal. If the decision remains in anyway adverse to the Veteran, issue him and his representative a Supplemental Statement of the Case (SSOC) and then return the case to the Board, if all is in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ Paul Sorisio Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs