Citation Nr: 1817271 Decision Date: 03/19/18 Archive Date: 03/30/18 DOCKET NO. 08-09 642 ) 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 low back pain, originally claimed as a back condition. 2. Entitlement to service connection for the residuals of a broken finger. 3. Entitlement to service connection for an acquired psychiatric disability, to include depression and a nervous condition. 4. Entitlement to service connection for bilateral hearing loss. 5. Entitlement to service connection for tinnitus. 6. Entitlement to service connection for obstructive sleep apnea. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Parsons, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1981 through October 1984. He then served in the Army Reserves from February 1985 through September 1991 and had several periods of active duty for training (ACDUTRA). These matters come before the Board of Veterans' Appeals (Board) on appeal from October 2007 and July 2016 rating decisions issued by a Department of Veterans Affairs (VA) regional office (RO). The Veteran appeared before the undersigned Veterans Law Judge in a January 2018 videoconference hearing. A transcript is of record. In January 2012, the Board reopened and remanded the issue of entitlement to service connection for low back pain. The Board also remanded the issues of entitlement to service connection for the residuals of a broken finger, entitlement to service connection for limitation of motion of the right hand, and entitlement to service connection for an acquired psychiatric disability for further development. In a June 2013 rating decision, entitlement to service connection for limitation of motion of the right hand was granted. This was considered a full grant of the claim on appeal, and the Board does not have jurisdiction over this issue. In February 2016, the issues of entitlement to service connection for bilateral hearing loss, entitlement to service connection for tinnitus, and entitlement to service connection for obstructive sleep apnea were remanded for further development. The development ordered by the January 2012 and February 2016 remand directives has been completed to the extent possible. The claims are again before the Board for appellate review. The issue of entitlement to service connection for residuals of a broken finger is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The most probative evidence of record does not reflect that the Veteran's currently diagnosed low back disability is etiologically linked to an in-service injury, event, or disease. 2. The most probative evidence of record does not reflect that the Veteran's currently diagnosed acquired psychiatric disability, to include depression and a nervous condition, is etiologically linked to an in-service injury, event, or disease. 3. The most probative evidence of record does not reflect that the Veteran's currently diagnosed bilateral hearing loss is etiologically linked to an in-service injury, event, or disease. 4. The most probative evidence of record does not reflect that the Veteran's currently diagnosed tinnitus is etiologically linked to an in-service injury, event, or disease. 5. The most probative evidence of record does not reflect that the Veteran's currently diagnosed obstructive sleep apnea is etiologically linked to an in-service injury, event, or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a low back disability have not been met. 38 U.S.C. §§ 1101, 1112, 1101, 1113, 1131, 1137, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.309 (2017). 2. The criteria for entitlement to service connection for an acquired psychiatric disability have not been met. 38 U.S.C. §§ 1101, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 3. The criteria for entitlement to service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1101, 1112, 1113, 1131, 1137, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2017). 4. The criteria for entitlement to service connection for tinnitus have not been met. 38 U.S.C. §§ 1101, 1101, 1112, 1113, 1131, 1137, 1154, 5107 (2012); 38 C.F.R. § 3.102, 3.303, 3.307, 3.309 (2017). 5. The criteria for entitlement to service connection for obstructive sleep apnea have not been met. 38 U.S.C. §§ 1101, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board acknowledges that the Veteran has not been afforded a VA medical examination with respect to his claim for entitlement to service connection for obstructive sleep apnea. However, the Board finds that a VA examination is not necessary in order to render a decision. The VA Secretary must provide a VA medical examination when there is: (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, and (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McClendon v. Nicholson, 20 Vet App. 79, 81 (2006). As will be discussed below, there is no competent evidence of record to suggest the Veteran's obstructive sleep apnea is related to his active duty service. Neither the Veteran nor his representative has raised any other issues with the duty to notify or duty to assist. See Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Thus, the Board need not discuss any potential issues in this regard. Further, the Veteran has not alleged any deficiency with the conduct of his hearing before the undersigned with respect to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). In this regard, the Federal Circuit ruled in Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016) that a Bryant hearing deficiency was subject to the doctrine of issue exhaustion as laid out in Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Thus, the Board need not discuss any potential Bryant problem because the Veteran has not raised that issue before the Board. Although evidence was received following the February 2017 statement of the case and the June 2013 supplemental statement of the case, the Veteran waived AOJ consideration of the additional evidence during his January 2018 Board hearing. The regulations pertinent to this decision were provided in the February 2008 and February 2017 statements of the case and most recently in the June 2013 supplemental statement of the case. Since he has had adequate notice of the pertinent laws, they will not be repeated here. Low Back Pain The Veteran contends his lumbar spine disability is etiologically related to his active duty service. Specifically, he reports that he injured his back while on active duty, and has had constant pain since. After a full review of the record, the Board finds that the most probative evidence of record is against a finding that the Veteran's lumbar spine spondylosis is etiologically related to his active duty service. Service treatment records indicate that in January 1984, the Veteran reported experiencing upper back pain for approximately one month. He could not recall a particular injury that caused his back pain and was diagnosed with a muscle strain. It was recommended he obtain x-rays and get further evaluation. The Veteran's service treatment records do not indicate he ever went for follow up treatment. During his January 2018 Board hearing, the Veteran testified that he was prescribed strong medication and bed rest and was put on a profile. His service treatment records contain no evidence he was prescribed bed rest or put on a profile. He also reported that he had trouble with his back while in jump school, but then testified that he did not complete any jumps during jump school. A review of the Veteran's personnel file indicates he was in an artillery battalion, but his military occupational specialty (MOS) was 76C10 equipment records and repair parts specialist while on active duty from October 1981 through October 1984. While in the reserves, he received training for motor transport operator and tactical satellite microwave systems operator. There is no indication he was ever in jump school. The Veteran did not report back pain on his report of medical history when he enlisted in the Army Reserves in February 1985, and no spine or other musculoskeletal abnormalities were noted on the clinical evaluation. A routine health evaluation conducted in July 1989 also did not note any back problems. The Veteran continued to serve with the Reserves until September 1991 without any recorded complaints of back pain. During his January 2018 Board hearing, he testified that he did not seek treatment for his back pain while he was in reserve service. A Labor Accident Report from the Commonwealth of Puerto Rico State Insurance Fund reflects that the Veteran injured his back in an occupational injury in November 1994. An October 1997 x-ray report reflected the Veteran had L5 spondylosis, no evidence of spondylolisthesis, his intervertebral disc spaces were preserved, vertebral heights were preserved, and there was no evidence of acute inflammatory or traumatic injury. In October 2000, the Veteran was diagnosed with chronic lower back pain due to spondylosis. The Veteran was afforded a VA examination to determine the etiology of his low back disability in February 2012. The Veteran reported that, during basic training, he was lifting heavy equipment and developed back pain. He also reported his 1994 occupational injury. An x-ray report dated November 2011 also documented minimal mid dorsal levosocoliosis with spondylosis deformans. The examiner carefully reviewed the claims file, including his January 1984 in-service report of back pain and November 1994 occupational injury, and concluded it was less likely than not that the Veteran's current low back disability was etiologically related to his active duty service. The examiner explained that the Veteran's January 1984 injury was described as pain between the shoulder blades (upper back) and no pathology at the thoracolumbar spine area was noted. The examiner further explained that the Veteran's November 1994 occupational injury may contribute to the current findings, but it was more probable that his spondylosis was related to the natural aging process. The examiner also opined that it was less likely than not that the Veteran's low back disability was aggravated beyond its natural progression by any period of ACDUTRA or inactive duty for training (INACDUTRA). The examiner noted that the Veteran's spondylosis was a mild condition without neurological deficits and he was treated with oral anti-inflammatory medications. The current findings corresponded to the natural progression of his condition, and were not aggravated. X-rays taken in May 2012 reflected no spondylolysis, no spondylolisthesis, and no abnormalities were identified involving the disc spaces, vertebra, facet joints, or neural foramina. The impression noted no lumbar spine abnormalities were identified radiographically. The Veteran was afforded a second VA examination to determine the etiology of his low back disability in January 2016. He reported that his back pain began during active duty, but he could not recall the date. The examination report noted that the Veteran was first diagnosed with lumbar spondylosis in 1997. The examiner opined it was less likely than not that the Veteran's lumbar spondylosis was etiologically related to his active duty service because his service treatment records indicated no treatment for the claimed condition and the objective or clinical evidence to supported that his current back condition began after separation from active duty. The Board finds the February 2012 and January 2016 VA examinations to be of great probative value. Both examiners thoroughly reviewed the Veteran's claims file, to include his January 1984 treatment for back pain, and opined it was less likely than not that the Veteran's lumbar spine spondylosis was related to his active duty service. The February 2012 examination report provided a thorough explanation, noting that the Veteran's spondylosis was a mild condition and most likely the result of the natural aging process. Although the Veteran consistently reported back pain since active duty service, none of his physicians have opined that his current back disability is etiologically related to his active duty service. The Board notes that "spondylosis" is a broad term used to describe many types of degenerative changes to the spine, including osteoarthritis, but is not a diagnosis of osteoarthritis. See https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697338/. However, the record does not reflect that the Veteran was diagnosed with spondylosis until October 1997. Therefore, the record does not reflect that the Veteran was diagnosed with degenerative changes, to include arthritis, to a compensable degree within one year of separation from active duty. There is also no evidence showing manifestations of arthritis during or within the first year after service. Thus, the presumptive service connection provision of 38 C.F.R. §§ 3.307(a)(3) and 3.309(a) for chronic disabilities are not applicable. While the Board recognizes the Veteran's assertions that his disability is related to service and is competent to testify as to events that occurred in military service, the Veteran is not competent to conclude that any condition he has now, over 20 years later, is connected to his service. Although lay persons are competent to provide opinions on some medical issues, the specific disabilities in this case, musculoskeletal issues, fall outside the realm of common knowledge of a lay person. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Musculoskeletal issues require specialized training and medical diagnostic testing for a determination as to diagnosis, and they are not susceptible of lay opinions on etiology. There are many different possible musculoskeletal issues, and a layperson is not competent to diagnose among them or to provide an etiology. Therefore, the Board finds that the Veteran's statements of record cannot be accepted as competent evidence sufficient to establish service connection for his disability. Indeed, the first evidence of lumbar spine pain after service was not until 1994, approximately 10 years after the Veteran's separation from active duty service, and was specifically related to an occupational injury. In specific regard to the Veteran's disability, continuity of symptomatology under 38 C.F.R. § 3.303(b) is not shown, as there is no competent or credible lay or medical evidence of post-service symptomatology. In fact, his Reserve examinations and medical histories conclusively refute any allegation that he had continuous symptoms after his 1984 treatment. There is no competent, credible medical or lay evidence linking the Veteran's current low back disability to his active duty service. The elements for service connection for a low back disability have not been met. Accordingly, service connection for the claimed disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against these claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53. Acquired Psychiatric Disorder The Veteran claims his acquired psychiatric disability, to include depression and a nervous condition, is related to service. Specifically, during his January 2018 hearing, he reported that the 1983 bombing of the American Embassy in Beirut "affected" him and he has felt overwhelmed and depressed ever since. After a full review of the record, the Board finds that the most probative evidence of record is against a finding that the Veteran's acquired psychiatric disability is etiologically related to his active duty service. Service treatment records indicate the Veteran initially reported experiencing depression or excessive worry on his October 1980 report of medical history, but corrected it to no depression or excessive worry. At separation from active duty in October 1984, he declined a separation examination and a physician determined an examination was not necessary. His service treatment records from October 1981 through October 1984 are silent for any reports of or treatment for a psychiatric disability. In February 1985, when he entered the reserves, he reported experiencing nervous trouble. The physician's notes recorded "nervous, mild when he was in basic training." The Veteran did not report depression or excessive worry. The Veteran underwent a routine health assessment in July 1989. On the report of medical history, he again reported nervous trouble, but no depression or excessive worry. The physician did not make any notes regarding the report of nervous trouble. Therefore, a psychiatric condition was not factually shown either during active duty or his reserve period. The record does not reflect that the Veteran reported any psychiatric conditions or symptoms until 2006. A March 2006 private medical record noted he was depressive, but feeling better. In September 2006, he sought treatment for depression. At the time he reported that he had lost his job due to his discouragement, he was very irritable, and did not sleep. The precipitating events were listed as a fight with his son in May 2006, multiple job losses, the Gulf War, his four children, and the death of his youngest child in 1992. The psychologist noted that the main factors for his depression were problems with work, family problems, and the loss of his job. The Veteran began seeking treatment for his psychiatric disability through the VA in July 2007. During his July 2007 Psychiatry Admission Evaluation, he reported that he did not have fears caused by a particular event or number of events. The Veteran underwent a second Psychiatry Admission Evaluation in July 2009. During that evaluation he identified work stressors, but did not report that his psychiatric symptoms were related to service in any way. In February 2008 he reported that his work was the main cause of his disturbance because it was monotonous and boring. The Veteran was afforded a VA examination in February 2012 to determine the etiology of his acquired psychiatric disability. During the examination, he vaguely reported "there were 243 injured people including civilian and military personnel" while at the border in 1983. He also reported that, while in Germany, he put a rifle in his mouth. The examiner carefully reviewed the claims file and found no complaints, psychiatric findings, or psychiatric treatment prior to military service. Although the Veteran reported experiencing nervousness in February 1985, the clinical evaluation made no neuropsychiatric findings, diagnoses, or treatment. The record reflected the Veteran did not seek psychiatric treatment until 2006, when he was diagnosed with major depression with the identified stressor of "primary support." He also entered substance abuse treatment from 2007 through 2008. Follow-up treatment for his psychiatric disability documented housing problems, financial problems, poor coping skills, and poor primary group support as identified stressors. The examiner opined it was less likely than not that the Veteran's acquired psychiatric disability was etiologically related to his active duty service. The Veteran was afforded another VA examination to determine the etiology of his acquired psychiatric disability in January 2016. Although the Veteran's service treatment records were not available for review during the examination, the examiner conducted a detailed review of his VA treatment records and the Veteran denied any treatment for a mental disorder while in military service. The examiner opined it was less likely than not that the Veteran's acquired psychiatric disorder was related to his active duty service because he was not treated for a psychiatric disorder until over 20 years after service and there was no presentation of anxiety or depressive symptomatology prior to that. The Board finds the February 2012 and January 2016 VA examinations to be highly probative. The February 2012 VA examiner considered the Veteran's military history and lay statements, including a claim that he saw 243 injured persons at the border in 1983. The examiner also noted the Veteran reported family and work stressors when he first sought treatment. During the January 2016 examination, the Veteran did not report any specific in-service events at all. The January 2016 examiner conducted a detained review of the Veteran's history of psychiatric treatment, noting that many of his early reports of depression and anxiety were attributed to family or work stressors. Both examiners determined it was less likely than not that the Veteran's acquired psychiatric disability was etiologically related to his active duty service. The Veteran did not first report to physicians that his acquired psychiatric symptoms were related to his active duty service until 2010. The Board does not find the reports of his military service to be credible. During his January 2018 Board hearing, the Veteran clarified that a 2007 medical record reflecting that he had returned from a year in Afghanistan was a "mistake" and he had never served in the Gulf War. However, this is not a situation where a single inaccuracy could be reasonably called a "mistake"; rather, the record is replete with several other inaccurate reports of his military service. In a January 2010 psychiatry note, he reported that he was active military at the Lebanon liberation in 1983 and active military in 1991 at the Persian Gulf War, non-combat in both events. In August 2010, he reported that while in service, his rank was reduced from an E4 to an E3 after an article 15 "due to fights with other soldiers." He also described his military experience as difficult and tense because he witnessed several military accidents where several people died. An October 2013 referral to the mental health clinic noted the Veteran was a Military Police officer and that was a factor in his inability to relax. A December 2013 psychiatry note reflected he had been anxious because he remembered the times he was in the desert, negative interactions between fellow soldiers, the 1983 bombing of the American embassy in Beirut, and several attacks while stationed in Germany. The Board does not find any of these reports of the nature of his service to be even remotely credible. While the Veteran did receive an article 15 that resulted in his reduction in rank, it was for failure to report to his assigned duty station, not fighting with other soldiers. The Veteran was also not a MP. As stated above, his military occupational specialty (MOS) was 76C10 equipment records and repair parts specialist while on active duty from October 1981 through October 1984. There is no indication in his personnel file that he was ever a MP. As for vague reports that he experienced "attacks" while in Germany, the Veteran's personnel file and service treatment records do not indicate that he witnessed or participated in any attacks to the base, other service members, or himself personally. Finally, the Veteran was not stationed in Lebanon in 1983 or at any other time during his active duty service. He was stationed at Fort Hood until July 1983 and arrived in Germany in August 1983, where he remained until September 1984, just prior to his separation from active duty. The Veteran's DD 214 reflects that the Veteran served one year, one month, and 11 days of foreign service, an amount of time that correlates exactly to the period he was stationed in Germany. There are no notes in his personnel file that he went TDY overseas or otherwise was stationed outside the United States or Germany. There is also no support for any claim that he was activated for the Persian Gulf War during his reserve service or that he ever served in a desert environment. Therefore to the extent any of the medical professionals relied on these inaccurate military histories, their opinions are uninformed and inaccurate. In July 2010, the Veteran reported that his military experiences were his main stressor. He reported that his psychiatric symptoms were due to military experiences again in August 2010, June 2011, November 2011, January 2013, and July 2016. However, as explained above, the Board does not find his report of his "military experiences" to be credible. Further, although the Veteran reported experiencing psychiatric symptoms since active duty service, none of his psychologists attributed his acquired psychiatric disability to active duty. A February 2014 psychiatric evaluation noted that the Veteran reported experiencing psychiatric symptoms since he was stationed in Germany in 1983. After speaking with the Veteran and conducting a full examination, the psychologist related the Veteran's symptoms of anxiety and depression to a general dissatisfaction with where he is in life and his relationship. The psychologist also noted behavior patterns that may be related to personality traits that contribute to his distress. To emphasize, after considering the Veteran's alleged military stressors, a VA psychologist attributed his psychiatric symptoms to non-military causes. The record indicates that the Veteran began seeking treatment in 2006 due to occupational, financial, and family stressors. It was only after his claim for service connection had been pending on appeal for years that the Veteran began to state he had experienced psychiatric symptoms since service or reported any in-service traumatic events such as seeing 243 injured service members and civilians. The Board finds that waiting for so long to report an event that would clearly have been traumatizing reduces the credibility of that report. The inconsistency of his statements over the past 12 years weigh against the claim that he experiences psychiatric symptoms related to his active duty service. His assertions are simply not credible in light of the voluminous evidence that, prior to 2011, he never once described his acquired psychiatric disability as due to his active duty service. Finally, the Board notes that the Veteran testified at his January 2018 hearing that he believed he had PTSD, but he affirmatively denied having been formally diagnosed with PTSD. A review of the Veteran's medical records does not show a PTSD diagnosis. In summary, for the reasons explained in detail above, entitlement to service connection for an acquired psychiatric disorder, to include depression and a nervous condition, is not warranted. The elements for service connection for an acquired psychiatric disability have not been met. Accordingly, service connection for the claimed disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against these claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53. Bilateral Hearing Loss and Tinnitus The Veteran claims his hearing loss is related to active duty service because he was exposed to acoustic trauma. During his January 2018 Board hearing he testified that he worked around heavy artillery. After a full review of the record, the Board finds that the most probative evidence of record is against a finding that the Veteran's bilateral hearing loss and tinnitus are etiologically related to his active duty service. The Veteran underwent several hearing tests while on active duty service and in the reserves. Audiometric testing conducted at induction in October 1980 reflected the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 5 10 10 LEFT 20 15 5 5 15 The Veteran was placed on a hearing conservation plan and his hearing was tested in June and December 1982. Audiometric testing results from June 1982 reflected the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 25 15 5 5 15 LEFT 20 15 15 15 15 Results from audiometric testing conducted in December 1982 reflected the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 25 15 5 10 5 LEFT 35 25 20 25 30 It was noted there was no significant shift of 20 decibels or more between June and December 1982. The Veteran enlisted in the reserves in February 1985. Audiometric testing taken at induction reflected puretone thresholds of: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 10 15 10 LEFT 20 20 5 15 15 Finally, the Veteran underwent audiometric testing in July 1989 as part of a routine health evaluation. Results of puretone testing reflected the following thresholds: HERTZ 500 1000 2000 3000 4000 RIGHT 15 25 20 25 30 LEFT 25 15 5 10 5 None of the results of audiometric testing from October 1980 through July 1989 demonstrated the Veteran had hearing loss for VA purposes. However, he did experience a hearing threshold shift in the right ear at 4000 Hertz. Post-service VA medical records note the Veteran affirmatively denied hearing loss and tinnitus in July 2011. In October 2013, the Veteran reported experiencing hearing loss and tinnitus. At the time, he claimed he heard well but reported periodic high pitched tinnitus bilaterally. Results from audiometric testing reflected the following puretone thresholds: HERTZ 500 1000 2000 3000 4000 Avg RIGHT 15 25 25 35 35 30 LEFT 20 20 30 30 35 28.75 His word discrimination scores were 100 percent bilaterally. Although it is unclear from the record whether the speech discrimination scores were conducted using the Maryland CNC word list, that does not render the audiometric testing inadequate because the Veteran's puretone thresholds in October 2013 did not reflect he had hearing loss for VA purposes. Although the audiologist noted the Veteran had 12 years of military service, he did not link the Veteran's reported hearing loss to in-service noise exposure. The Veteran was afforded an examination to determine the etiology of his hearing loss and tinnitus in July 2016. Audiometric testing reflected the following puretone threshold results: HERTZ 500 1000 2000 3000 4000 Avg RIGHT 35 30 40 45 40 28.75 LEFT 40 40 50 45 45 17.5 His controlled speech discrimination test (Maryland CNC) showed speech recognition scores of 96 percent bilaterally. The examiner noted that although the Veteran demonstrated hearing loss for VA purposes in July 2016, it was less likely than not that his hearing loss was etiologically related to his active duty service. The examiner noted that the Veteran's audiograms from 1980 through 1989 showed his hearing was within normal limits, and he did not report hearing loss until October 2013. Audiometric test results in October 2013 similarly did not reflect the Veteran had hearing loss for VA purposes. The examiner noted it was well known that prolonged exposure to noise from short-term high intensity noise, such as the military type, could result in irreversible hearing loss. Hearing loss could be caused either immediately after a noise trauma or gradually during a period of noise exposure. However, there was no evidence of retroactive combined effect expected to be seen for hearing loss with onset so many years after being exposed to military noise. Alternatively, his hearing loss may have been associated with the combined effect of post-service occupational noise exposure and the normal aging process due to progressing outer hair cell dysfunction. With regard to the Veteran's tinnitus, the examiner noted that his tinnitus was a symptom known to be associated with clinical hearing loss. However, the Veteran did not report tinnitus while in service, and as the Veteran's hearing loss was not related to in-service acoustic trauma, but was most likely the combined effect of post-service occupational and/or recreational noise exposure and/or the normal aging process, the examiner opined it was less likely than not that the Veteran's tinnitus was related to his active duty service. The Board finds the July 2016 VA examination to be highly probative. The examiner considered the Veteran's lay statements and reviewed the entire claims file, including his several in-service audiometric evaluations, and opined it was less likely than not that the Veteran would have onset of bilateral hearing loss and tinnitus 20 years after his in-service noise exposure. Additionally, the October 2013 audiologist did not provide a nexus statement linking the Veteran's reported hearing loss to his active duty service. There are no other audiometric results in the record to indicate that the Veteran has a hearing loss disability or tinnitus related to his active duty service. Accordingly, the claims for service connection for bilateral hearing loss and tinnitus are denied. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply and the claim must be denied. 38 U.S.C. § 5107(b) (2012); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Obstructive Sleep Apnea The Veteran asserts that his sleep apnea is related to his active duty service. He argued during his January 2018 Board hearing that in 1983 or 1984 he experienced trouble sleeping and would wake up tired. He also testified that his roommates would complain because he snored loudly. After a full review of the record, the Board finds that the most probative evidence of record is against a finding that the Veteran's obstructive sleep apnea is etiologically related to his active duty service. Service treatment records reflect that the Veteran reported frequent trouble sleeping on his October 1980 induction examination and his July 1989 routine health evaluation. During both examinations, the physician did not note any sleep or breathing problems on the clinical evaluation or address any sleep problems in the section reserved for the physician's summary. Post-service treatment records reflect the Veteran reported that he had sleep disturbances and lack of energy in August 2008, but these symptoms were associated with his acquired psychiatric disorder. The record does not reflect that the Veteran reported fragmented sleep, daytime tiredness, or snoring until May 2011, when it was recommended he be referred for a sleep study to rule out sleep apnea. He was diagnosed with sleep apnea in November 2012 after undergoing a sleep study. In his substantive appeal, the Veteran reported that he experienced snoring while on active duty and would wake up gasping for breath because he could not breathe in his sleep. He also reported daytime drowsiness. The lay statements and testimony have been considered in this decision. While the Veteran's reports of daytime drowsiness and snoring are capable of lay observation, the Board finds that the causes of his currently diagnosed sleep apnea are not capable of lay observation, and the Veteran does not have medical training. Drowsiness could be caused by a variety of medical conditions and is not necessarily indicative of sleep apnea. As such, the Veteran's opinions are afforded little weight in the analysis of whether a nexus between his current sleep apnea and his service. There is no objective or lay evidence to suggest that the Veteran's sleep apnea is related to his active duty service. He did not report symptoms indicative of sleep apnea until May 2011, and was not diagnosed with severe obstructive sleep apnea until November 2012, 21 years after he separated from the reserves and 28 years after he separated from active duty service. The elements for service connection for obstructive sleep apnea have not been met. Accordingly, service connection for the claimed disability is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against this claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53. ORDER Entitlement to service connection for low back pain, claimed as a back condition is denied. Entitlement to service connection for an acquired psychiatric disability is denied. Entitlement to service connection for bilateral hearing loss is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for obstructive sleep apnea is denied. REMAND The Veteran claims service connection for residuals of a broken finger. Specifically, the Veteran contends that he continues to experience residual pain and swelling following a fracture of his fifth metacarpal. The Veteran was afforded a VA examination to determine the etiology of the residuals of his right fifth metacarpal fracture in February 2012. The examiner found no evidence of swelling to the Veteran's right hand, but he reported pain on palpation to the metacarpal and ulnar border. The examiner also noted that the January 2010 bone scan did not reflect any arthritis or residual fracture. Although the February 2012 VA examiner found no evidence of arthritis or residual fracture, x-rays ordered in conjunction with the examination, but not conducted until March 2012, reflected mild degenerative changes and an old posttraumatic deformity of the fifth metacarpal. As the February 2012 VA examiner's opinion that the Veteran did not have any arthritis or residual fracture of his fifth right metacarpal was based on an incomplete record, the Board finds a VA medical addendum opinion is necessary to address the noted posttraumatic deformity of the fifth metacarpal and determine the etiology of his right hand degenerative changes. The Board notes that the Veteran is currently in receipt of a noncompensable rating for limitation of motion of his right hand, specifically for limitation of motion of his right fifth metacarpal. Thus, only symptoms other than limitation of motion should be addressed. Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran's claims file to the VA physician who provided the opinion in 2012, or another medical professional if that individual is not available, for an opinion as to whether it is more, less, or equally likely that the Veteran experiences any residuals of his right finger fracture other than limitation of motion of the right hand/fifth finger (he has already been granted service connection for that symptom). The examiner should specifically address whether the posttraumatic deformity of the fifth metacarpal and the right hand degenerative changes are more, less, or equally likely due to the in-service injury to the fifth finger. 2. The AOJ should then readjudicate the claim. If the benefits sought on appeal remain denied, the Veteran and his representative should be provided a supplemental statement of the case. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board 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). ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs