Citation Nr: 1807317 Decision Date: 02/05/18 Archive Date: 02/14/18 DOCKET NO. 12-04 948 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a heart disorder, to include as secondary to service-connected Chiblain's of the hands and feet. 2. Entitlement to service connection for a lung disorder. 3. Entitlement to service connection for a bilateral knee disorder. 4. Entitlement to service connection for a low back disorder. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL The Veteran and her spouse ATTORNEY FOR THE BOARD K. Osegueda, Counsel INTRODUCTION The Veteran served on active duty from November 1985 to November 1989 with subsequent service in the United States Army Reserves. This case initially came before the Board of Veterans' Appeals (Board) on appeal from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In a March 2010 rating decision, the RO denied entitlement to service connection for a lung disorder, a bilateral knee disorder, and a low back disorder. In an April 2013 rating decision, the RO denied entitlement to service connection for congestive heart failure or mitral valve prolapse secondary to service-connected residuals of Chilblain's of the hands and feet. In May 2015, the Veteran testified at a hearing before the undersigned Veterans Law Judge at the RO. A transcript of the hearing has been associated with the record. In September 2015, the Board remanded the case to the Agency of Original Jurisdiction (AOJ) for additional development. That development has been completed, and the case has since been returned to the Board for appellate review. The Board notes that the Veteran's appeal also originally included the issue of entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD). However, in a May 2017 rating decision, the Appeals Management Center (AMC) granted service connection for PTSD with depression due to personal trauma. The AMC's grant of service connection constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Therefore, that matter is no longer on appeal, and no further consideration is necessary. The issues of entitlement to service connection for a bilateral knee disorder and a low back disorder are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran does not have a current heart disorder. 2. The Veteran does not have a current lung disorder. CONCLUSIONS OF LAW 1. A heart disorder was not incurred in active service, may not be presumed to have been so incurred, and is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). 2. A lung disorder was not incurred in active service. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Neither the Veteran nor her representative has raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The term "chronic disease," whether as manifest during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 U.S.C. § 1101 and 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In this case, there is no evidence showing that the Veteran has one of the enumerated diseases, such as arteriosclerosis (including coronary artery disease) and bronchiectasis. I. Heart Disorder In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a heart disorder. As a preliminary matter, the Board finds that the record does not show that a heart disorder manifested during the Veteran's active service. In this regard, the Veteran's service treatment records are negative for any complaints, treatment, or diagnosis pertaining to her heart. Service treatment records dated in December 1988 indicated that the Veteran was hospitalized for right upper quadrant abdominal pain that radiated to her back. However, a December 1988 chest x-ray showed no evidence of cardiomegaly, and a December 1988 EKG showed a normal sinus rhythm and heart rate of 65 beats per minute with normal axis and intervals. The EKG also showed no evidence of ischemia or injury. The service treatment records indicate that the Veteran was hospitalized at the 130th Station Hospital in Heidelberg, Germany, from December 28, 1988, to December 30, 1988, and that she was discharged with a final diagnosis of viral gastroenteritis. An October 1990 Individual Ready Reserves examination noted a normal clinical evaluation of the heart. However, the examining medical officer noted that the Veteran had exertional angina and needed a maximum graded exercise test (GXT) and further evaluation for ischemic heart disease. In an associated report of medical history, the Veteran denied having a history of palpitation, pounding heart, or heart trouble. In an October 1990 cardiovascular questionnaire, the Veteran reported that she had pain or discomfort in her chest. She also indicated that she had a family history of heart pain. An October 1990 consultation request from the 301st Field Hospital indicated that the Veteran's Army Over-40 Medical Screen suggested the possibility of a cardiovascular condition. The associated consultation report noted a positive family history. The Veteran described exertional angina with left arm and hand pain and radiation. The physician noted that the Veteran needed a maximum GXT and further evaluation. October 1990 chest x-rays were within normal limits. An October 1990 EKG was also within normal limits. In July 1994, the Veteran was hospitalized for a cardiac evaluation after she complained of pleuritic chest pain that radiated to her left arm. In a July 1994 VA discharge summary, a physician noted that the Veteran had a history of chest pain and a normal cardiac catheterization in the past. A coronary examination revealed regular heart rate and rhythm, and an EKG showed a normal sinus rhythm and no acute changes. A chest x-ray was also clear, and there was no cardiomegaly. In addition, there was no evidence of arrhythmia on a 24-hour telemetry monitoring. In a March 1995 VA treatment note, the Veteran complained of chest pain or pressure and swelling in her legs. She stated that she had a lot of right-sided chest discomfort anteriorly and under her right arm. She described a sharp, knife-like pain that did not increase with respiration. In a September 1995 VA treatment note, the Veteran reported that she was treated for angina-like chest pain in the past year and that a catheter was normal. She related that she had two episodes of chest pain since that time while she was under stress. In a November 2002 VA discharge note, the discharging physician noted that the Veteran was admitted with atypical chest pain in the center of her chest, both shoulders, and the left side for three days. A cardiac catheterization showed normal coronary arteries, normal left ventricular ejection fraction and wall motion, normal hemodynamics, and evidence of catheter-induced coronary spasm that was relieved with intracoronary nitroglycerin. A cardiac cause of the chest pain was ruled out. The physician related that the Veteran's chest pain may be related to severe reflux rather than cardiac chest pain. In a December 2003 VA emergency department note, the Veteran complained of a sharp chest pain that radiated up the side of her neck with initial shortness of breath. The evaluating physician noted that the Veteran had a normal heart catheterization in November 2002. An EKG showed sinus rhythm at 78 beats per minute and no ST elevation. Chest x-rays showed no acute disease. The physician related that she felt that the Veteran's symptoms were unlikely cardiac in nature because she had a normal coronary catheterization in the past year. A March 2004 VA treatment note included findings from an abnormal chest x-ray dated in February 2004. The impression suggested concern for a mild degree of heart failure. The interpreter noted, however, that the Veteran's slightly reduced lung volumes may have accentuated the heart size and pulmonary vasculature. A follow-up chest x-ray was ordered to determine whether improved inflation of the lungs showed the absence of the findings on the film. An April 2004 VA echocardiogram report showed normal chamber dimensions; normal valves; normal left ventricular wall motion and global systolic function; normal right ventricular systolic function; and no evidence for intracardiac shunt. In a November 2011 VA treatment note, the Veteran complained of new onset chest pain that began the day before. She stated that she had at least five episodes of chest pain lasting approximately five minutes during each episode. She described a pressure that radiated to her bilateral posterior shoulders. She also related that she had numbness and tingling down her left arm with the events. She indicated that she developed edema to her bilateral lower extremities and shortness of breath days prior to her chest pain. She reported that she had a history of a heart catheterization in 2003 with stent placement. Her heart rate was 78 beats per minute with a regular rhythm. In a November 2011 private hospital history and physical note, the intake nurse noted that the Veteran had been transferred by the VA emergency room to the private hospital. The nurse documented the Veteran's complaints of intermittent chest pain over a course of a few days. She related that it was occasionally associated with activity and also occurred at rest. She described a midsubsternal chest ache that lasted 20 minutes at a time. It did not radiate and was not pleuritic in nature. There were no palpitations. A cardiovascular examination was normal. The physician noted that the chest pain was atypical in nature and that myocardial infarction would be ruled out. A cardiologist was consulted, and the Veteran was admitted for further testing and continuous telemetry monitoring. In a November 2011 private cardiology consultation note, the Veteran reported a history of coronary artery disease, status-post percutaneous coronary intervention with stent in 2003. She presented to the emergency room with complaints of bilateral lower extremity edema for days and intermittent chest pain that radiated to her left scapula and left arm. A cardiac examination was normal. Cardiac enzymes were negative, and a chest x-ray was negative for congestive heart failure. An EKG was benign and showed a normal sinus rhythm. The cardiologist's impression included chest pain with notes to rule out acute coronary syndrome, congestive heart failure, and pulmonary embolism. A November 2011 private cardiolite exercise stress test was essentially normal. There was no chest pain, ST shift, or arrhythmias with exercise, and the Veteran demonstrated good exercise capacity. There was no evidence for ischemia by EKG or symptom criteria. A November 2011 private myocardial perfusion scan was normal and showed a left ventricular ejection fraction of 67 percent with normal wall motion. A November 2011 private EKG revealed a normal left ventricular chamber size, normal global left ventricular wall motion and contractility, and normal left ventricular systolic function. The estimated ejection fraction was 55 to 60 percent. Mild aortic regurgitation, mild mitral regurgitation, and mild tricuspid regurgitation were noted by color flow Doppler. A November 2011 private chest x-ray showed no evidence of active cardiopulmonary disease. November 2011 private discharge instructions indicated that the Veteran was discharged with a diagnosis of angina. An April 2012 VA problem list indicated that the Veteran was diagnosed with mild aortic valve insufficiency and mild mitral valve insufficiency in December 2011. During an April 2012 VA history and physical, the intake nurse noted that the Veteran was admitted to a private hospital the day before for chest pain radiating to her right lower jaw and left neck with dizziness, shortness of breath, nausea, and lower extremity swelling. An EKG was normal, and cardiac enzymes were negative. It was noted that she had a negative stress test in November 2011 with a left ventricular ejection fraction of 55 to 60 percent. The Veteran stated that the chest pain was located mainly in her left parascapular region and that it was usually positional and not always related to physical exertion. The intake nurse indicated that a 2002 VA cardiac stress test was normal and that the Veteran demonstrated no symptoms during testing. She also noted that a 2002 VA cardiac catheterization showed normal coronary arteries, normal left ventricular ejection fraction and wall motion, normal hemodynamics, and evidence of catheter induced coronary spasm that was relieved. During an April 2012 VA cardiology consultation, the Veteran reported a five day history of diffuse edema of her hands, feet, and face with spells of chest pressure and tightness, dyspnea, diaphoresis, and jaw or neck pain with activities such as ambulation and transferring from her bed. The examining cardiology resident indicated that the Veteran's EKG's and labs at the private hospital and at the VA Medical Center (VAMC) had been within normal limits without evidence for acute coronary syndrome (ACS) due to elevated cardiac biomarkers or ischemic EKG changes. A cardiac examination was normal, as was an EKG. The examining cardiology resident noted that the Veteran had coronary artery disease risk factors of family history; hypertension; and resolved recent unstable angina. There was no evidence for active ischemic process or angina. An April 2012 VA echocardiogram revealed normal left ventricular systolic function, mild left ventricular hypertrophy, an estimated ejection fraction of 67 percent, mild mitral insufficiency, trivial aortic regurgitation, mild left atrial enlargement, and no pericardial effusion. In an April 2012 VA addendum opinion, the cardiologist noted that he agreed with the cardiology resident's assessment, but he was not convinced that the Veteran's symptoms were cardiac-related. He noted that the Veteran had a cardiac catheterization in 2002, which was reported as normal, and she had a normal stress test in November 2011. An April 2012 computed tomography angiogram (CTA) showed mild stenosis of the proximal first diagonal and a short segment of myocardial bridging of the distal first diagonal and mid left anterior descending artery (LAD). During a January 2013 VA heart examination, the Veteran indicated that she had a left heart catheterization in November 2002, which was normal and showed a normal ejection fraction. She related that she did not have a stent in 2003, as recorded in the November 2011 private history and physical from her earlier hospitalization for chest pain. The VA examiner noted that the Veteran was hospitalized in November 2011 with complaints of chest pain, but coronary artery disease and congestive heart failure were both ruled out. An examination revealed a rate of 68 beats per minute with regular rhythm. The examiner noted abnormal heart sounds with a mild systolic murmur at the RSB. There was no jugular-venous distension; peripheral pulses were normal; and there was no peripheral edema. The VA examiner opined that the Veteran's claimed heart disorder was less likely than not proximately due to or the result of her service-connected Chiblain's. Rather, the VA examiner determined that there was no evidence of any heart conditions. She indicated that private medical records showed no coronary artery disease with stent in 2003 and a negative catheterization. She also observed that there was no evidence of congestive heart failure in 2011 and that diagnostic testing was normal. In addition, she related that there was no myocardial infarction in 2011 and that the Veteran's enzymes, troponin, and myocardial stress test were normal. She further noted that there was no evidence of mitral valve prolapse. She related that 2011 and 2012 EKGs showed mild mitral, aortic, and tricuspid regurgitation. The VA examiner reported that Chiblain's did not usually result in permanent injury and that there was no temporal relationship between any claimed heart condition and Chiblain's. During a May 2015 hearing, the Veteran testified that she was hospitalized in Heidelberg, Germany, for chest pain for two days in December 1988. She stated that she was evaluated and diagnosed with angina at that time. She also stated that she was diagnosed with congestive heart failure by a VA physician in 2012. A December 2016 EKG revealed normal sinus bradycardia. During an April 2017 VA heart examination, the Veteran reported a history of a mild heart attack. She stated that she had chest pain in 2003 with a cardiac catheterization that showed no blocked arteries. She denied the placement of a stent. She indicated that she had chest pain again in 2012 and that she was hospitalized and underwent a cardiac evaluation. She denied any evaluation or treatment for a heart condition since 2012. The examiner noted that the Veteran did not have and had never been diagnosed with a heart condition. On examination, the Veteran's heart rate was recorded as 68 beats per minute with a regular rhythm. Heart sounds and peripheral pulses were normal, and there was no peripheral edema. The examiner noted that a 2011 chest x-ray was normal and that a 2011 echocardiogram was normal and showed a left ventricular ejection fraction of 55 to 60 percent with normal wall motion. The examiner reported no diagnosis and noted that the Veteran had a structurally and functionally normal heart. In addition, the April 2017 VA examiner found no evidence of a myocardial infarction in 2011, as the Veteran's cardiac enzymes and troponin, stress test, left heart catheterization, echocardiogram, B-type natriuretic peptide (BNP), and chest x-rays were normal. The examiner noted that the November 2011 echocardiogram report documented physiological mild valvular regurgitation, which is an incidental, normal finding without pathological relevance. She explained that nearly all of the normal population would have a finding of some trivial or mild degree of regurgitation of one, two, or three heart valves on a normal echocardiogram. She stated that this is called "physiologic" regurgitation and is an incidental finding that does not need any type of follow-up or treatment. She also noted that many cardiologists choose not to mention it to patients to avoid anxiety for the common and benign finding. The April 2017 VA examiner also opined that there was no temporal relationship between any claimed heart condition and Chiblain's. She explained that there is no epidemiologic evidence of such causal relation. After a review of all the evidence of record, the Board finds that service connection for a heart disorder is not warranted. The term "disability" as used for VA purposes refers to impairment of earning capacity. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. Thus, in the absence of proof of a present disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, like an abnormal laboratory finding, an abnormality such as physiological mild valvular regurgitation disclosed by diagnostic examination that results in no objective symptomatology is not a disability for VA purposes, because there is no industrial impairment. See, e.g., 38 C.F.R. §§ 4.1, 4.10; 61 Fed. Reg. 20,440, 20,445 (May 7, 1996) (Diagnoses such as hyperlipidemia, elevated triglycerides, and elevated cholesterol are actually laboratory results and are not, in and of themselves, disabilities, and are not appropriate entities for the rating schedule). The Board finds that the weight of the evidence demonstrates that the Veteran does not have a heart disability. As a result, the claim must fail. In the absence of a present disability there can be no claim. Brammer, 3 Vet. App. at 225. The Board recognizes that the Court has held that the presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, where the overall record shows no diagnosis of the claimed disability, as in the case here, that holding would not apply. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. §§ 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has a disability for which benefits are claimed. In this case, where the evidence shows no current disability upon which to predicate a grant of service connection, at any time during the claim period, there can be no valid claim for that benefit. See Brammer at 225; Rabideau, 2 Vet. App. 141, 143-44 (1992). Moreover, the April 2017 VA examiner also opined that there was no temporal relationship between any claimed heart condition and the Veteran's service-connected Chiblain's. She explained that there is no epidemiologic evidence of such causal relation. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a heart disorder, and the claim must be denied. As the preponderance of the evidence is against the claim for service connection for a heart disorder, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. II. Lung Disorder In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for a lung disorder. An August 1985 enlistment examination noted a normal clinical evaluation of the lungs and chest. In an associated report of medical history, the Veteran indicated that she had a history of asthma. A December 1985 service treatment note documented a diagnosis of laryngitis. In a January 1986 service treatment record, the Veteran complained of a head cold and congestion. She was diagnosed with an upper respiratory infection. In February 1986, the Veteran complained of a productive cough for three weeks. Her chest was clear to auscultation. The diagnosis was probable sinusitis. In October 1987, the Veteran was treated for a cough or sinus problem. The examining aidman noted that the Veteran was prescribed a cold pack and Decoramine. He noted that she was prescribed the same in May 1987 and that she had some improvement of her symptoms at that time. In a January 1988 service treatment record, the Veteran complained of pain in her chest and coughing after being exposed to cold weather for three days at Fort Dix. Her chest was clear to auscultation. She was diagnosed with a viral syndrome. In March 1988, the Veteran was diagnosed with an upper respiratory infection. In April 1988, the Veteran complained of a productive cough and nasal congestion. She was diagnosed with bronchitis. In May 1988, the Veteran complained of a bad cough. She was diagnosed with a cold. A December 1988 chest x-ray showed increased lung markings in the lower lung fields. There was no evidence of focal infiltrates. In a January 1989 service treatment record, the Veteran complained of productive coughing with nasal discharge and congestion. She was diagnosed with a cold. An April 1989 chest x-ray showed no significant abnormality. In a May 1989 service treatment record, the Veteran complained that she was coughing up blood. The diagnosis was probable upper respiratory infection or viral bronchitis. The examining medical officer indicated that he doubted that she had pneumonia. A chest x-ray was ordered to rule out pneumonia versus bronchitis, and the x-ray was negative. An October 1994 Individual Ready Reserves examination noted a normal clinical evaluation of the lungs and chest. In an associated report of medical history, the Veteran denied having asthma, shortness of breath, and chronic cough. She did note that she was treated for an upper respiratory infection in 1988 while she was stationed in Heidelberg. In a January 1998 VA treatment note, the Veteran complained of a productive cough for approximately one week. The physician diagnosed her with acute bronchitis. In an April 2000 VA treatment note, the physician noted that a March 2000 VA chest x-ray was read as possibly a bilateral necrotizing pneumonia. On physical examination and chest x-ray, the physician found no current evidence of infiltrate. In a March 2002 VA treatment note, the Veteran complained of a three week history of cough with sputum production. She denied having a history of asthma and allergic rhinitis; she endorsed a history of upper respiratory infections and sinusitis. She was diagnosed with bronchitis with bronchospasms. A February 2004 VA chest x-ray showed slightly reduced lung volumes. The interpreter noted that there was no evidence of pneumonia to account for the Veteran's cough. In a December 2008 VA treatment note, the Veteran reported a history of "walking pneumonia" in 2000. During a March 2010 VA cold injury protocol examination, the Veteran stated that she was out in an open field with no shelter in the below freezing temperatures with sleet and strong wind for several hours during a training exercise while in basic training at Fort Dix because her transport broke down. She related that she was hospitalized in November 1985 for two and a half weeks at Fort Dix with hypothermia, frostbite, stiffness in her joints, and heaviness in the chest that progressed to pneumonia. She also stated that she was treated for recurrent upper respiratory infections in 1986 and 1987 while she was stationed in Heidelberg, Germany, and was treated for pneumonia in 2002 at the VAMC in Gainesville, Florida. An August 2010 VA treatment record shows that the Veteran complained of a dry cough for ten months. She also indicated that she had several upper respiratory infections in the past winter. She reported that she had nasal congestion, some postnasal drip, and a worsened cough at night. She denied any dyspnea. She related that she had many respiratory infections when she was stationed in Germany during service, including a hospitalization during which she had difficulty with wheezing. She denied being diagnosed with asthma. On examination, her lungs were clear to auscultation, and her respiratory effort was normal. The physician diagnosed the Veteran with a chronic cough and noted that it could be a variant of asthma. A repeat chest x-ray and PFTs were ordered and a referral to a pulmonologist was to be considered if the Veteran's symptoms did not improve. A September 2010 pulmonary function test showed a pre-bronchodilator FEV1/FVC percentage of 79 percent and a post-bronchodilator FEV1/FVC percentage of 77 percent. In a March 2012 VA treatment note, the Veteran complained of a nonproductive cough for three days. She complained of some dyspnea on exertion and occasional wheezing. The diagnosis was acute bronchitis, and she was started on an albuterol inhaler. A July 2014 VA chest x-ray showed no evidence of consolidation, effusion, or pneumothorax. The impression was no acute cardiopulmonary process. During a January 2015 VA respiratory conditions examination, the Veteran reported that she was exposed to cold weather during basic training at Fort Dix and developed pneumonia. She stated that she had subsequent upper respiratory infections while she was stationed in Germany. She related that she continued to get sick with upper respiratory infections following service and that she was treated for pneumonia in 2000 and bronchitis in 2008. She indicated that she occasionally had a cough and shortness of breath and that she had a granuloma in her lung that was caused by pneumonia. She denied having childhood asthma, and she stated that she was never diagnosed with asthma or chronic obstructive pulmonary disease. She denied smoking. The VA examiner opined that the Veteran did not have and was never diagnosed with a respiratory condition. The examiner noted that a June 2014 VA chest x-ray showed no acute cardiopulmonary process. The examiner noted that there were no current clinical findings or medical evidence to support a diagnosis of a respiratory condition. Therefore, she opined that the claimed lung disorder was less likely than not incurred in or caused by service. She noted that the Veteran's service treatment records showed that the Veteran was treated for acute onset of cold symptoms (upper respiratory infection) during service. She stated that the records did not show any chronic respiratory condition. She related that the upper respiratory conditions in service were acute and transitory. In addition, the examiner noted that VA treatment records showed no evidence of a chronic respiratory condition. She stated that the Veteran was diagnosed with acute bronchitis in 2008, which was treated and was not chronic. She also noted that the Veteran's enlistment report of medical history showed that the Veteran noted a history of childhood asthma until she was 10 years old, but the service treatment records did not show any asthma condition. The examiner further related that a granuloma shown on chest x-ray and CT was a small area of inflammation in the tissue resulting from an infection. She explained that it was usually benign and did not require treatment. She also indicated that the granuloma was not found on the Veteran's chest x-ray during service. After a review of all the evidence of record, the Board finds that service connection for a lung disorder is not warranted. Again, the Board notes that the existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. §§ 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that interpretation of sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that the Veteran currently has a disability for which benefits are claimed. In this case, where the evidence shows no current disability upon which to predicate a grant of service connection, at any time during the claim period, there can be no valid claim for that benefit. See Brammer at 225; Rabideau, 2 Vet. App. 141, 143-44 (1992). The January 2015 VA examiner opined that the Veteran did not have and was never diagnosed with a respiratory condition. Moreover, she opined that the Veteran's claimed lung disorder was less likely than not incurred in or caused by service. She noted that the Veteran had been treated for acute respiratory symptoms, such as upper respiratory infections and bronchitis, that had resolved and that the Veteran did not have a chronic disability related to her acute illnesses in service. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a lung disorder, and the claim must be denied. As the preponderance of the evidence is against the claim for service connection for a lung disorder, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for a heart disorder is denied. Service connection for a lung disorder is denied. REMAND In September 2015, the Board, in pertinent part, remanded the case to the AOJ to afford the Veteran VA examinations to determine the nature and etiology of any bilateral knee and low back disorders that may be present. In April 2017, the Veteran was afforded VA knee and back examinations. In the VA knees examination report, the VA examiner opined that the Veteran was less likely than not to have a bilateral knee disorder incurred in, caused by, a result of, or aggravated by active military service. He reasoned that the objective evidence found an absence of the Veteran's bilateral knee disorder being incurred in, caused by, a result of, or aggravated by active military service. In the VA back conditions examination report, the VA examiner diagnosed the Veteran with degenerative disease of the lumbar spine, thoracic spine spondylosis, and left L5 radiculopathy. He opined that the Veteran's degenerative disease of the lumbar spine, thoracic spine spondylosis, and left L5 radiculopathy were less likely than not to have been incurred in, caused by, a result of, or aggravated by active military service. He reasoned that the objective evidence found an absence of the Veteran's degenerative disease of the lumbar spine, thoracic spine spondylosis, and left L5 radiculopathy being incurred in, caused by, a result of, or aggravated by active military service. In both examination reports, the VA examiner did not provide supporting rationale for his opinions. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, the Board finds that an additional medical opinion is needed. Accordingly, the case is REMANDED for the following action: 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for a bilateral knee disorder and a low back disorder. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After the above development has been completed, the AOJ should refer the Veteran's claims folder to the April 2017 VA examiner or, if he is unavailable, to another suitably qualified VA examiner for a clarifying opinion as to the nature and etiology of any current bilateral knee disorder. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and the Veteran's own assertions. It should also be noted that the Veteran is competent to attest to matters of which she has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a bilateral knee disorder that is causally or etiologically related to her military service. In making this determination, the examiner should consider the Veteran's May 2015 Board hearing testimony in which she indicated that she initially injured her left knee in a fall on ice trying to get satellite dishes and generators set up in the field and that she injured her right knee in the field when she fell down holding a satellite dish during a storm. She stated that she was placed on restricted duty in 1987 and then reinjured her knees in the field. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. After the above development has been completed, the AOJ should refer the Veteran's claims folder to the April 2017 VA examiner or, if he is unavailable, to another suitably qualified VA examiner for a clarifying opinion as to the nature and etiology of any current low back disorder. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and the Veteran's own assertions. It should be noted that the Veteran is competent to attest to factual matters of which she had first-hand knowledge, such as observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has a low back disorder that is causally or etiologically related to her military service. In making this determination, the examiner should consider the Veteran's May 2015 Board hearing testimony in which she indicated that she initially injured her low back while preparing for a field exercise. She indicated that she was loading a truck, slipped on ice, and hit her back and tailbone on a trailer. She indicated that she was subsequently put on a 90-day profile for restricted duty to an orderly room. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history[,]" 38 C.F.R. § 4.1, copies of all pertinent records in the appellant's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. The AOJ should then review the claims file and ensure that all of the foregoing development actions have been conducted and completed in compliance with the directives. If any development is incomplete, appropriate corrective action should be implemented. The AOJ should also conduct any other development deemed necessary as a result of the actions taken in the preceding paragraphs. 5. When the development requested has been completed, the case should be reviewed by the AOJ on the basis of additional evidence. If the benefits sought are not granted, the Veteran and her representative should be furnished a supplemental statement of the case (SSOC) and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matters 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 or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs