Citation Nr: 19151389 Decision Date: 07/02/19 Archive Date: 07/02/19 DOCKET NO. 09-01 893 DATE: July 2, 2019 ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for a pulmonary or respiratory disability is denied. Entitlement to service connection for a cervical spine disability is denied. Entitlement to service connection for a lumbar spine disability is denied. Entitlement to service connection for a bilateral shoulder disability is denied. Entitlement to service connection for a right hip disability is denied. Entitlement to service connection for a left hip disability is denied. Entitlement to service connection for bilateral knee disability is denied. Entitlement to service connection for a bilateral ankle disability is denied. Entitlement to service connection for drug or medication dependency is denied. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is denied. REMAND Entitlement to service connection for right ear hearing loss is remanded. FINDINGS OF FACT 1. The Veteran did not serve in the Republic of Vietnam and was not otherwise exposed to herbicide agents during service. 2. The Veteran did not have hazardous exposure to lead or ionizing radiation during service, and he did not engage in combat with the enemy during service. 3. The Veteran’s hypertension did not manifest to a compensable degree within one year after service, continuity of symptomatology is not established, and the preponderance of the evidence is against finding that the disability began during service or is otherwise related to an in-service injury, event, or disease. 4. The Veteran does not have bronchiectasis, and the preponderance of the evidence is against a finding that a current pulmonary or respiratory disability is related to an in-service injury, event, or disease. 5. The Veteran’s cervical spine, lumbar spine, bilateral shoulder, right hip, bilateral knee, and bilateral ankle disabilities, to include arthritis or gout, did not manifest to a compensable degree within one year after service, continuity of symptomatology is not established, and the preponderance of the evidence is against finding that the current disabilities began during service or are otherwise related to an in-service injury, event, or disease. 6. The Veteran does not have a current left hip disability, including based on pain. 7. The Veteran does not have a current drug or medication dependency disability. 8. The Veteran’s service-connected disabilities do not render him unable to secure and follow a substantially gainful occupation consistent with his education and occupational experiences. CONCLUSIONS OF LAW 1. The criteria for service connection for hypertension are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a pulmonary or respiratory disability are not met. 38 U.S.C. §§ 1110, 1111, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 3. The criteria for service connection for a cervical spine disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for a lumbar spine disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 5. The criteria for service connection for a bilateral shoulder disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for service connection for a right hip disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 7. The criteria for service connection for a left hip disability are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for service connection for a bilateral knee disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 9. The criteria for service connection for a bilateral ankle disability are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 10. The criteria for service connection for drug or medication dependency are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 11. The criteria for a TDIU are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.340, 3.341, 4.1, 4.3, 4.16. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the U.S. Navy from May 1971 to February 1973. This appeal proceeds from February 2002, March 2008, June 2010, and August 2014 rating decisions. After several remands, the Board denied all issues on appeal in an August 2018 decision. The Veteran appealed to the U.S. Court of Appeals for Veterans Claims (Court). In a March 2019 Order, the Court vacated and remanded that decision pursuant to the terms of a Joint Motion for Remand by the parties. The Veteran testified before the undersigned Veterans Law Judge in a January 2011 hearing with respect to several issues on appeal; those issues were remanded in February 2012. The Veteran also testified before a second Veterans Law Judge in a July 2014 hearing with respect to some of those same issues and other issues on appeal. The Veteran was advised of his right to a hearing before a third Veterans Law Judge as to the issues that overlapped between the two hearings that would be addressed in a panel decision; he declined a third hearing in May 2015. In August 2015, the Board issued two separate decisions. A panel decision, signed by both the undersigned January 2011 Veterans Law Judge and the July 2014 Veterans Law Judge, remanded the claims for service connection for hypertension, a pulmonary or respiratory disorder, arthritis of the cervical spine, lumbar spine, shoulders, hips, knees, and ankles. The second decision, signed by the July 2014 Veterans Law Judge alone, remanded the claims for service connection for right ear hearing loss, drug or medication dependency, and a TDIU. The Veterans Law Judge who conducted the July 2014 hearing is no longer available. The Veteran was notified of this and offered an opportunity for another Board hearing, and he declined a new Board hearing in a February 2018 response. As such, the Veteran's claims are consolidated and addressed in a single decision. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. Generally, there must be evidence of these three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases, including hypertension, arthritis, and bronchiectasis, will be presumed related to service if they were noted or diagnosed as chronic in service; or if they manifested to a compensable degree within one year following active duty discharge; or if chronicity or continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a)(3). VA will presume that a veteran was exposed to herbicide agents (including Agent Orange) if he or she served in the Republic of Vietnam between January 9, 1962, and May 7, 1975. 38 U.S.C. § 1116; 38 C.F.R. § 3.307(a)(6). This presumption includes service that involves duty or visitation to Vietnam, and service on a ship in the inland waters of Vietnam or within the 12-nautical mile territorial sea from the shores of Vietnam. See Procopio v. Wilkie, 913 F.3d 1371 (Fed. Cir. 2019). Certain listed conditions will be presumed related to such exposure if the condition manifested to a degree of 10 percent or more after service. 38 C.F.R. § 3.309(e). If the presumptive provisions are not met, service connection still may be established with proof of direct exposure or direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Stefl v. Nicholson, 21 Vet. App. 120 (2007). In adjudicating such claims, reasonable doubt that exists because of an approximate balance of positive and negative evidence concerning any point will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board will first address the Veteran’s contentions concerning in-service events that are common to most of his claims in order to avoid unnecessary repetition. Herbicide Agent (Agent Orange) Exposure The Veteran asserts that all of his claimed disabilities except for drug or medication dependence are due to in-service exposure to herbicide agents (Agent Orange). See, e.g., June 2007 formal claim (VA 21-526, as noted in 2019 Joint Motion for Remand); October 2009 informal claim; January 2011 hearing transcript; July 2014 hearing transcript; April 2018 Veteran statement. In the August 2018 initial denial, the Board found that service connection was not warranted for any of the Veteran’s claimed conditions on this basis because the evidence did not establish herbicide agent exposure. The March 2019 Court Order via Joint Motion for Remand vacated and remanded that decision as to the service connection issues based on a finding that the Board did not adequately explain why there was no actual herbicide agent exposure, as discussed further below. Contrary to the Veteran’s assertion in an April 2019 correspondence, the Joint Motion did not state that the Veteran’s herbicide exposure shall not be denied. The Board first emphasizes that none of the Veteran’s claimed conditions are eligible for service connection on a presumptive basis as due to herbicide agent exposure. See 38 C.F.R. § 3.309(e). As discussed further under each issue below, the Veteran has current diagnoses of hypertension, sensorineural hearing loss, pulmonary or respiratory conditions of restrictive lung disease and chronic bronchitis, gout, and arthritis of the cervical spine, lumbar spine, right hip, bilateral shoulders, knees, and ankles. He does not have a diagnosis for his left hip. There are no diagnoses of cancer, peripheral neuropathy, or other listed conditions that may be presumptively service-connected based on herbicide agent exposure. There is also no medical evidence to indicate that there may be a non-presumptive link between any of the claimed current disabilities and any herbicide agent exposure during service. Although the Veteran believes his conditions are due to such exposure, he is not competent to offer an opinion in this regard. This is a complex question that requires knowledge of the multiple involved bodily systems and the effects of herbicide agents, as well as interpretation of the Veteran’s medical history. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Without a presumptive disability or an indication that there may be a link to herbicide agent exposure, service connection cannot be established on this basis. Moreover, the evidence continues to establish no presumptive or actual herbicide agent exposure. Concerning the presumption, there is no indication in service treatment or personnel records that the Veteran served on the ground or in the waters of Vietnam from 1971 to 1973, and the Veteran specifically testified that he was never in Vietnam. See July 2014 hearing transcript (p.11). The Veteran’s DD Form 214 reflects that he was attached to Fighter Squadron 44 and was assigned to the U.S.S. Franklin Delano Roosevelt (CVA042) (USS FDR). There is also no argument or indication that this ship was within the 12-nautical mile territorial sea from the shores of Vietnam during the period of the Veteran’s service. The August 2015 panel Board remand noted that the Veteran’s was attached to Fighter Squadron 44, which may have been assigned to Japan, Korea, or Thailand at various times. However, the Veteran clarified in October 2015 and January 2016 letters that he was in Fighter Squadron 84, not 44, and that he not in or near Thailand but, instead, was deployed on the USS FDR in the Mediterranean Sea. He reported in April 2017 that he was at sea near the coast of Florida. The notation of Fighter Squadron 44 in the prior Board remand was in error, as the DD Form 214 and other service records reflect that the Veteran was in Fighter Squadron 84 (also called VF-84 or Fitron 84). Therefore, there is no argument or suggestion that the Veteran served in Thailand or in the waters offshore from Vietnam. The Veteran’s representative asserted generally in a June 2019 brief that the Veteran’s military records were incomplete because there should be more information about his conduct and discharge, including relating to being put in the brig for using hashish. However, there is no indication that records concerning the Veteran’s assignments, ship locations, or presence or exposure to herbicide agents are missing, or that a further remand would have any reasonable possibility of obtaining records that may aid in substantiating his claim in this regard. Concerning actual exposure, the Veteran contends that he was exposed to herbicide agents including Agent Orange while repairing and maintaining engines of F4-J aircraft that had flown through or landed in Vietnam while he was stationed on the USS FDR. He also reports that he attached tanks of herbicide agents to the aircraft and that fluid will spill out of the tanks at times. See, e.g., 2011 and 2014 hearing transcripts; April 2017 report of general information. In the August 2015 panel remand, the Board directed the agency of original jurisdiction (AOJ) to associate with the claims file a Joint Services Records Research Center (JSRRC) memorandum included in the M21-1MR, Training Letter 10-06, and the January 2015 Institute of Medicine (IOM) Report on C-123 aircraft and reservists’ herbicide exposure. Upon further review of the file, the Board notes that the May 2009 JSRRC memorandum was associated with the file in April 2013, now labeled as “Third Party Correspondence.” Otherwise, the AOJ did not associate the requested documents with the file. However, since the issuance of the August 2011 remand, the M21-1MR has been replaced by the M21-1 and Training Letter 10-06 has been revoked. Additionally, the Veteran has not asserted that he worked on or was exposed to C-123 aircraft, and there is no indication that he was an Air Force Reservist during the applicable timeframe. Therefore, a remand for this purpose would not have a reasonable possibility of aiding in substantiating the claim and would only result in unnecessary delay. The March 2019 Court Order via Joint Motion for Remand found that the Board improperly relied on a non-binding M21-1 provision about herbicide agent exposure without independently reviewing the JSRRC memorandum upon which that provision was based. See Overton v. Wilkie, 30 Vet. App. 257 (2018). The M21-1 provides that a May 2009 JSRRC memorandum will be associated with the claims file where the Veteran asserts exposure based on shipboard herbicide agent transportation, storage, or use. VBA Manual M21-1, IV.ii.1.H.2.m (last accessed June 17, 2019). As noted above, that memorandum is in the Veteran’s claims file. The M21-1 provision merely notes that the memorandum should be associated with the file, not what effect it should have on the claim. As noted in the Joint Motion, the May 2009 JSRRC memorandum states that the JSRRC “has found no evidence that indicates Navy or Coast Guard ships transported tactical herbicides from the U.S. to the Republic of Vietnam or that ships operating off the coast of Vietnam used, stored, tested, or transported tactical herbicides.” In addition, the JSRRC stated that it “cannot document or verify that a shipboard Veteran was exposed to tactical herbicides based on contact with aircraft that flew over Vietnam or equipment that was used in Vietnam.” The memorandum notes that the JSRRC reviewed numerous official military documents, ship histories, deck logs, and other sources of information related to Navy and Coast Guard ships and the use of herbicide agents such as Agent Orange during the Vietnam Era to come to these conclusions. Although the M21-1 provision is not binding on the Board, the Veteran and his representative have been made aware of the contents of the memorandum itself, and there has been no argument that the memorandum is inadequate. Upon independent review, the Board finds the JSRRC memorandum highly probative because it is based on extensive official research. There is also no evidence to contradict the JSRRC’s findings for the Veteran’s individual case. There is no evidence of herbicide agent exposure in the Veteran’s service treatment or personnel records in the claims file. The AOJ requested any documents showing herbicide exposure from the Veteran’s service records and received a negative response in November 2001. A May 2013 memorandum by the AOJ further notes that a November 2012 list of ships that have been determined to be associated with herbicide exposure did not include the USS FDR. This list has been updated through March 2019 and still does not include the USS FDR. A May 2017 memorandum from the JSRRC provides the history for the Veteran’s squadron, VF-84, but only for 1970 and not for the years of the Veteran’s service from 1971 to 1973. In light of the JSRRC’s guidance in the 2009 memorandum that herbicide agents were not transported, stored, or used aboard US Navy vessels at any time, a remand to obtain additional information from the JSRRC has no reasonable possibility of assisting in substantiating the claim and is not necessary. As a lay person, the Veteran’s assertions of exposure to gases or chemicals during service are not sufficient evidence alone to establish that such an event actually occurred during service. Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Although the Veteran is competent to describe what he experienced and witnessed in service, there is no evidence that he is competent to determine what, if any, chemicals or gases adhered to the exterior of aircraft or were washed off aircraft while aboard the USS FDR, or that herbicide agents were transported, stored, or used aboard the ship. He has not provided evidence, other than his own lay reports, to show that there were herbicide agents on the ship or the aircrafts. There is no indication in his service records of actual herbicide agent exposure. As such, the evidence is not sufficient to establish that the Veteran was exposed to herbicide agents when cleaning aircraft or loading herbicide agents onto aircraft. Accordingly, exposure to herbicide agents has not been established on a presumptive or actual basis. These contentions will not be addressed further. Lead Exposure The Veteran also contends that all of his claimed conditions except for drug or medication dependency are due to exposure to lead during service. He states that lead paint was used to paint the ship he was on when it was built in 1949. See, e.g., July 2001 claim, 2014 hearing transcript, April 2018 correspondence (“other”). Although the Veteran believes he was exposed to lead during service, his lay assertions of such exposure to are not sufficient to establish that this actually occurred. Bardwell, 24 Vet. App. 36. There is no evidence that he has any expertise concerning the nature of chemicals or that he is competent to determine whether he was exposed to lead or any effect such exposure may have had on him, to include whether he had lead poisoning. The Veteran has not provided any evidence other than his own lay reports to show that he was exposed to lead or other toxic chemicals during service. In February 2016, he submitted a general “lead paint poisoning notice” dated in March 2011, which notes that paints containing excessive amounts of lead were widely used in homes prior to 1978 and that care should be taken to ensure that children do not eat chips of paint or plaster in older homes. This does not establish lead exposure or poisoning during the Veteran’s service. In fact, it suggests that lead paint must be ingested to result in lead poisoning, and the Veteran has not asserted that he ingested lead paint. An August 4, 2017 VA examiner noted that medical literature reflects that the etiology or nature of lead exposure is primarily through inhalation or ingestion. However, there is no competent indication that simply being on a ship that may have been painted with lead paint in the past would result in inhalation of lead paint fumes. The Veteran has not asserted that he inhaled lead paint fumes, such as during construction or repainting activities on the ship. There is also no indication in his service records of exposure to lead through paint or otherwise. The August 4, 2017 VA examiner also stated that the factual and clinical data in the Veteran’s file were negative for exposure, including by ingestion or inhalation, to lead paint or other toxins based on his service duties and medical records. The August 15, 2017 VA examiner likewise stated that there was no evidence of lead exposure or poisoning. As such, the evidence does not establish exposure to lead or other toxic chemicals during service, or that the Veteran had any lead poisoning due to such exposure. Moreover, there is no medical evidence to indicate that there may be a link between any of the claimed current disabilities and any potential lead exposure during service. The Veteran is not competent to provide an opinion in this regard. This is a complex question that requires knowledge of the multiple involved bodily systems and the effects of lead exposure, as well as interpretation of the Veteran’s medical history. Jandreau, 492 F.3d at 1377. The medical evidence is negative. The August 4, 2017 examiner opined that the Veteran’s claimed conditions were less likely than not related to any lead exposure during service. The examiner noted the permissible level of lead exposure set forth in an Office of Safety and Health Administration (OSHA) report. She also stated that although there was no blood level testing for the Veteran, the available evidence was negative for any exposure to lead paint or other toxins in service. This was based on a review of the Veteran’s military personnel records, active duty and presumptive period treatment records, factual information, and clinical data. The examiner noted that there were no clinical presentations necessitating a blood lead level work-up and no central or peripheral neurovascular symptomatology due to occupational exposure to lead. The examiner cited medical evidence in support of these conclusions. This examiner noted that medical literature does not support a nexus between hypertension and lead paint exposure. The examiner further noted that medical literature suggests a risk of gout in individuals with elevated blood lead levels, but she reiterated that the evidence does not establish lead exposure in this case. These opinions are highly probative because they reflect application of medical expertise to the available evidence for the facts in the Veteran’s individual case and are supported by a well-reasoned rationale. There is no contrary medical evidence to support a finding of lead exposure in service or a link to a current disability. Accordingly, lead exposure or poisoning during service has not been established, and there no competent indication that a current disability may be due to any such exposure. The Veteran’s contentions in this regard will not be addressed further. Radiation Exposure The Veteran also contends that all of his claimed conditions except for drug or medication dependency are due to possible radiation exposure in service. He stated in his July 2001 claim that it was unknown whether he was exposed to ionizing radiation, and that he was exposed to radiation from atmospheric testing or from aircraft engine heat on the ship or flight deck. Although the Veteran believes he may have been exposed to radiation during service, his lay assertions of such exposure to are not sufficient to establish that this actually occurred. Bardwell, 24 Vet. App. 36. There is no evidence that he has any expertise concerning the nature of radiation or that he is competent to determine whether he was exposed to radiation or any effect such exposure may have had on him. The Veteran has not provided any evidence other than his own lay reports to show that he was exposed to radiation during service, and even those reports are vague or reference possible radiation from engine heat, which is not ionizing radiation. In 2001, the AOJ requested any service personnel records to confirm radiation risk activity for the Veteran, including a radiation risk exposure form (DD Form 1141). There was no DD Form 1141 of record, and there is no other indication in his service records of exposure to radiation. Accordingly, exposure to radiation during service has not been established in this case. The Veteran’s contentions in this regard will not be addressed further. Combat The Veteran has asserted that several of his conditions are due to combat service. He states that he received combat pay or hazard duty pay while aboard the USS FDR aircraft carrier in the Vietnam era. See, e.g., April 2008 notice of disagreement, September 2010 and March 2014 correspondence. Under the combat presumption, where the evidence shows that a veteran engaged in combat with the enemy during active service, his or her lay reports will be sufficient to establish that an injury or disease was incurred or aggravated during combat, as long as such reports are consistent with the circumstances, conditions, or hardships of such service. This is true even if there is no official record of the incurrence or aggravation, unless there is clear and convincing evidence to the contrary. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). This presumption also extends to a combat veteran’s reports of a permanent disability beginning during combat. See Reeves v Shinseki, 682 F.3d 988, 998-1000 (Fed. Cir. 2012). The evidence does not establish combat service to trigger this presumption. The Veteran did not receive any awards, decorations, or medals that reflect combat service, and receipt of hazard duty pay does not establish that he or his unit engaged in combat with the enemy. There is a distinction between service in a hazardous environment or during a time of war and actually engaging in combat for this presumption, and the Veteran has not asserted that any actual combat incidents occurred aboard his assigned ship. Therefore, the Veteran’s lay assertions are not sufficient to establish the incurrence of an injury or disease or disability that began during combat service. This contention will not be addressed further. 1. Service connection for hypertension Other than exposure to herbicide agents, lead paint, radiation, and combat, which are discussed above, the Veteran has asserted that his hypertension is due to the stress of service on the flight deck or drug use while on the ship. He also asserts that his hypertension began during service with symptoms including headaches, or that the condition began within one year after service. See, e.g., July 2001 claim, April 2008 notice of disagreement, 2011 and 2014 hearing transcripts. The Board concludes that the chronic disease presumption does not apply, and there is no direct link to service. Although the Veteran has current hypertension, which is a chronic disease under 38 C.F.R. § 3.309(a), it was not noted or diagnosed as chronic during service, it did not manifest to a compensable degree within one year after service, and chronicity or continuity of symptomatology is not established. The evidence also does not establish a direct nexus between the Veteran’s current hypertension and an in-service injury, event or disease. The Veteran is competent to report the nature and timing of noticeable symptoms, as well as what he recalls as to when he started medications and when medical providers told him he had hypertension. However, his reports of hypertension beginning during service or within one year after service and continuing since that time are not credible due to inconsistency with other more probative evidence. Specifically, service treatment records do not contain any complaints or notations of high blood pressure or hypertension. During his January 1973 separation examination, the Veteran’s blood pressure reading was 98/64, and no hypertension was noted. This evidence is highly probative because it was created at the time of the events. The April 2013 and August 4, 2017 VA examiners expressly noted that the readings at service entry and exit were normal or negative for hypertension, and a January 2016 VA examiner also noted that there was no evidence of hypertension in service records. Although the Veteran asserted in a February 2016 correspondence that the June 2016 examiner used the wrong sized blood pressure cuff, that relates to his current blood pressure readings, and a diagnosis of hypertension has been established. The first documented medical diagnosis of hypertension is in November 2001 treatment records, nearly 30 years after service. The Veteran reported having hypertension for many years for treatment in 2001. A lack of medical documentation prior to 2001 does not necessarily mean that hypertension did not exist; however, the Veteran’s reports as to the date of onset of his hypertension and prescribed medications have been internally inconsistent. In a July 1998 claim for service connection, the Veteran reported an onset in 1975. In a July 2001 claim, he reported an onset in 1973 with treatment beginning in 1975. A November 2001 private treatment record reflects that the Veteran reported having hypertension for 27 years, or since approximately 1974. A November 2001 VA treatment record noted that the Veteran reported having longstanding hypertension and that he did not take medications because they caused headaches. In a September 2008 report for his Social Security Administration (SSA) claim, the Veteran stated that he was first prescribed medication for hypertension in 1985. In a September 2009 VA claim, the Veteran reported treatment for hypertension in 1983 and 1984. Similarly, during the 2011 Board hearing, the Veteran reported that he was first diagnosed in 1984 by a private provider, and that he had high blood pressure readings between 1973 and 1984 but was not medicated for it. He stated that his blood pressure readings from 1973 to 1974 were “borderline” but not high enough to be medicated. During an April 2013 VA examination, he reported being diagnosed with hypertension in 1974 when he began having headaches and that he had been on medications since that time. He denied being told in service that he had hypertension. During a January 2016 VA examination, the Veteran reported a date of diagnosis as 1974 but stated that he began taking medications in 1973. During a July 2017 VA examination, he reported an onset of hypertension in 1973. The above reports have little probative weight because they are internally inconsistent. These are more than minor inconsistencies, as the Veteran gave dates ranging from 1973 to 1975 and from 1983 to 1985 for when his diagnosis and treatment for hypertension began. When he gave more detail, he appeared to clarify that he was not actually diagnosed or medicated until the 1980s, several years after service, which directly contradicts his other reports of being diagnosed and medicated within one year after service. Moreover, the Veteran’s report for treatment in 2001 that he did not take medications for hypertension because they caused headaches also contradicts his assertions at other times that headaches during service were a symptom of his hypertension and that he was diagnosed with hypertension within the year after service based on symptoms of headaches. In light of these inconsistencies, the Board finds that the Veteran is not credible as to having had ongoing high blood pressure or hypertension during service or within one year after service or needing medication within one year after service. To reach the compensable level to trigger the chronic disease presumption, hypertension must either require continuous medication for control or have diastolic pressure of predominantly 100 or more or systolic pressure of predominantly 160 or more. See 38 C.F.R. § 4.104, Diagnostic Code 7101. As discussed above, the most probative evidence does not establish such readings or medication during the Veteran’s service or within one year after service, by February 1974, or continuous symptoms thereafter. Therefore, the chronic disease presumption does not establish service connection. 38 C.F.R. §§ 3.303(b), 3.307(a), 3.309(a)(3). Concerning a direct link, the Veteran is not competent to provide an opinion as to whether any stress he experienced during service resulted in hypertension or whether headaches at that time were a manifestation of hypertension. These are medically complex questions that require knowledge of the cardiovascular system and interpretation of the Veteran’s medical history. Jandreau, 492 F.3d at 1377. As to the Veteran’s assertions that drug use in service resulted in hypertension, as his claim was received after October 31, 1990, service connection may not be granted if the disability was the result of the Veteran’s abuse of alcohol or drugs. 38 C.F.R. § 3.301(a); Allen v. Principi, 237 F.3d 1368, 1376 (Fed. Cir. 2001). The medical evidence does not establish a link between the Veteran’s current hypertension and service. The Veteran submitted private medical opinions from Dr. N in January 2011 and June 2013, which state that the Veteran’s hypertension is due to service. Both of these letters indicate that this opinion is based on the Veteran’s report that he has had hypertension since active service and that he did not have hypertension prior to service. This rationale is based on an inaccurate factual premise, as the Board finds the Veteran not credible as to having had hypertension since service or within the one year after service. Dr. N provided no other rationale. Therefore, Dr. N’s opinions have no probative value. In contrast, VA examiners in April 2013, June 2017, and two examiners in August 2017 opined that the Veteran’s current hypertension is not at least as likely as not related to service. These opinions were based on a review of the claims file along with consideration of the Veteran’s reports. The April 2013 examiner explained that the Veteran did not have elevated blood pressure readings during service, including at his separation examination, there were no records showing an onset within one year of service, and the Veteran gave conflicting accounts as to the date of onset. This examiner further noted that the 2011 private nexus opinion did not have a rationale. The June 2017 examiner noted the Veteran’s report of an onset of hypertension in 1973 but explained that there was no significant information in medical records to show that he had hypertension during service or within one year after service. Similarly, the August 4, 2017 examiner explained that there were no signs or symptoms of hypertension in service records, including the entrance and separation examinations or interim records, or in records during the presumptive period (one year after service). The August 15, 2017 examiner similarly stated that the Veteran did not have hypertension during active duty and his report of being diagnosed within one year after service was not supported by the medical evidence. These opinions are highly probative and persuasive because they reflect application of medical expertise to the Veteran’s accurate factual and medical history, consistent with the Board’s credibility findings herein, and include a well-reasoned rationale. As discussed above and incorporated herein, the evidence also does not establish that the Veteran’s hypertension is due to any in-service exposure to herbicide agents, lead paint or poisoning, or radiation, or that it began in combat. In summary, the preponderance of the evidence is against finding that the Veteran’s current hypertension is related to service under any reasonably raised theory. There is no reasonable doubt to resolve, and the appeal is denied. 2. Service connection for respiratory or pulmonary disability Other than exposure to herbicide agents, lead paint, radiation, and combat, which are discussed above, the Veteran has asserted that his current respiratory or pulmonary disability is related to his symptoms and diagnosis of bronchitis during service and continued symptoms since that time. He also asserts that he had bronchiectasis during service to warrant presumptive service connection. See, e.g., June 2010 notice of disagreement, February 2016 correspondence, April 2018 correspondence (labeled “other”), 2011 and 2014 hearing transcripts. The Board concludes that the chronic disease presumption does not apply, and there is no direct link to service. The Veteran does not have bronchiectasis or another listed chronic disease under 38 C.F.R. § 3.309(a). Although the Veteran has a current pulmonary or respiratory diagnosis and was treated for bronchitis and respiratory symptoms during service, the evidence does not establish a direct nexus between the Veteran’s current disability and an in-service injury, event or disease. Concerning a current disability, although the Veteran is competent to describe his observable symptoms and his recollection as to what providers told him about his condition, he is not competent to identify the underlying diagnosis. This is a medically complex question that requires knowledge of the pulmonary and respiratory systems and interpretation of his medical history. Jandreau, 492 F.3d at 1377. Medical evidence notes several diagnoses, but not bronchiectasis. An April 2013 VA examiner diagnosed asthma and noted that VA treatment records in 2010 suspected seasonal allergies for the Veteran’s cough. A June 2017 VA examiner diagnosed chronic bronchitis and restrictive lung disease due to obesity. Although bronchiectasis was a choice for diagnosis, neither examiner diagnosed that condition. VA examiners in August 2017 noted similar diagnoses. Private provider Dr. N stated in January 2011 and June 2013 letters that the Veteran had bronchiectasis that included bronchitis. However, those letters indicate that Dr. N had not treated the Veteran for this condition and that this notation was based on the Veteran’s self-report, which is not competent. Additionally, the August 4, 2017 VA examiner noted that bronchiectasis has a different medical definition than bronchitis. Thus, Dr. N’s letters have little to no probative value. They are outweighed by the more probative VA examiners’ diagnoses that reflect consideration of the Veteran’s and medical history based on available records. Concerning a nexus to service, the Board initially notes that there are some suggestions of a preexisting condition or symptoms. During the April 2013 VA examination, the Veteran reported that he could not recall if he had asthma as a child, but that he thought he was treated for seasonal allergies and used an inhaler as a child. He further stated that he was told in the mid-1970s (or during service) that he could have had asthma, but that he was not given a diagnosis at that time. A veteran is presumed to be in sound condition upon entry into service, except for defects, infirmities, or disorders that are noted when examined, accepted, and enrolled for service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304. A history of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions, but it will be considered together with all other material evidence in determinations as to inception. 38 C.F.R. § 3.304(b)(1); see also Crowe v. Brown, 7 Vet. App. 238, 245 (1994). Although the presumption of soundness is rebuttable, the burden is on VA to do so through clear and unmistakable evidence both that the disability existed prior to service, and that such disability was not aggravated by service. 38 C.F.R. § 3.304(b); see also Wagner v. Principi, 370 F.3d 1089, 1096-97 (2004); VAOPGCPREC 3-2003. In a February 1971 Report of Medical History for his service entrance examination, the Veteran reported a history of headaches, chronic or frequent colds, sinusitis, hay fever, shortness of breath, and chronic cough. The service examiner noted a history of headaches, upper respiratory infection (URI), sinus, and hay fever that were not considered disabling (NCD). His lungs and chest were found to be clinically normal upon examination. Thus, the Veteran is presumed to have been in sound condition upon entrance into service. 38 C.F.R. § 3.304(b). VA has not met its burden to rebut this presumption. There are contemporaneous findings that the Veteran’s lungs and chest were clinically normal at induction and at his January 1973 separation examination. Although several VA examiners opined that the Veteran likely had a pulmonary condition prior to service, as discussed in detail below, none has opined that the condition clearly and unmistakably existed prior to service; this is a higher standard. As the presumption of soundness has not been rebutted, the general service connection requirements apply, and service connection will be granted if the evidence shows that the current disability began during or is otherwise related to an in-service injury or disease. Service records reflect repeated treatment for pulmonary or respiratory symptoms. Twice in July 1971, the Veteran was treated for an upper respiratory infection( URI). In April 1972, he was treated for a cold with symptoms of a sore throat and productive cough; his chest was clear. In May 1972, he complained of nausea and vomiting and was diagnosed with viral syndrome and removed from the flight deck. In July 1972, he was diagnosed with a viral URI. In September 1972, the Veteran was diagnosed with acute bronchitis based on complaints of extreme shortness of breath, headache, and coughing up phlegm. In November 1972, the Veteran again complained of shortness of breath, feeling tired and coughing frequently. He had erythema of the pharynx and wheezing but no rhales, and the plan was observation, fluids, and rest. The Veteran has made competent reports that he had symptoms including shortness of breath continuously since service. However, the Board finds these reports are not credible due to inconsistency with other more probative evidence in the record. During the April 2013 VA examination, the Veteran first reported shortness of breath since service, but then stated that he was diagnosed with chronic obstructive pulmonary disease (COPD) in the 1980s after he developed shortness of breath. These statements are internally inconsistent and inconsistent with other records. Specifically, the Veteran’s chest and lungs were clinically normal and a chest X-ray was within normal limits at his January 1973 separation examination. Available private treatment records do not note any pulmonary or respiratory complaints or diagnoses. VA treatment records include multiple chest X-rays from November 2001 to October 2010 that showed clear lungs, with no abnormalities or active lung disease. These X-rays in 2001, 2004, 2005, and 2010 did not indicate a history of respiratory or pulmonary symptoms; instead, they were conducted for routine or cardiac purposes. The Veteran repeatedly denied shortness of breath or cough, including in November 2001 and May 2002, and there were no respiratory diagnoses or reported symptoms from 2001 to 2010. An April 2002 record noted signs and symptoms of hypertension including shortness of breath, but no respiratory or pulmonary diagnosis was mentioned. The Veteran later denied hypertension symptoms including shortness of breath in January 2003. In September 2004, the Veteran reported a respiratory system history of sinusitis, not asthma, shortness of breath, COPD, cough, or other conditions. He reported smoking in the past. The Veteran also did not list any respiratory or pulmonary conditions or medications for his SSA claim, including in September 2008. For VA treatment in October and December 2010, the Veteran reported a cough and the diagnosis was suspected seasonal allergies. Later in December 2010, he reported that his cough was better but that he noticed shortness of breath when going for walks. He was prescribed albuterol (an inhaler) for breathing as needed prior to exercise, and this prescription continued through February 2013. VA chest X-rays in April 2013 and November 2015 showed a granuloma in the right lobe, but the lungs were otherwise clear and there was no active disease. A June 2017 chest X-ray also showed no acute or active disease, and the impression noted that low lung volumes were likely related to poor inspiratory effort and body habitus. During the June 2016 VA examination, the Veteran reported using left over albuterol inhalers as needed and that he sometimes coughed up colored phlegm. During the June 2017 VA examination, the Veteran reported using Mucinex for mucus or congestion, having seasonal bronchitis symptoms, and using antibiotics or an inhaler as needed. During the August 15, 2017 VA examination, the Veteran reported that he had bronchitis symptoms that come and go and that he took Mucinex or used an inhaler as needed, and that he had a past smoking history. The Veteran’s above reports for medical treatment are generally consistent with each other. These reports are highly probative as to the nature and timing of his conditions because they are contemporaneous in time to the actual symptoms and he had an incentive to report an accurate history in order to receive proper care. It is reasonable to assume that the Veteran would reported ongoing symptoms such as shortness of breath, or a history of respiratory or pulmonary diagnoses, when he sought treatment if they existed at those times. Instead, he expressly denied shortness of breath or cough many times for VA treatment. He first mentioned such symptoms in 2002 as related to hypertension, which he later denied in 2003, and in 2010 as related to possible allergies or exercising. The first lung abnormality was shown in a 2013 X-ray. The Veteran’s reports for treatment directly contradict his recollection for his VA claim of having symptoms since service. The medical records are more probative and outweigh his contrary reports. Thus, the evidence does not establish ongoing respiratory symptoms since service. The Veteran is not competent to provide an opinion as to whether any symptoms or diagnoses during service are related to his current disability. This is a medically complex question that requires knowledge of the pulmonary and respiratory systems and interpretation of his medical history. Jandreau, 492 F.3d at 1377. The medical evidence does not establish a link between the Veteran’s current pulmonary or respiratory disability and service. The Veteran submitted private opinions from Dr. N in January 2011 and June 2013, which state that the Veteran has bronchiectasis including bronchitis due to service. Both of these letters indicate that this opinion is based on the Veteran’s report that he has had this condition since service and that he did not have it prior to service. This rationale is based on an inaccurate factual premise, as the Board finds the Veteran not credible as to having had pulmonary or respiratory symptoms since service. Dr. N provided no other rationale. Therefore, Dr. N’s opinions have little to no probative value. In contrast, several VA examiners addressed the nature and etiology of the current condition based on a review of the claims file in addition to the Veteran’s reports. The April 2013 examiner gave a current diagnosis of asthma and opined that the claimed condition was less likely than not related to service, including the in-service diagnosis of shortness of breath and acute bronchitis in 1972. The examiner explained that acute bronchitis is usually bacterial, and there was only one documented episode, so no chronicity was shown. The report as a whole reflects consideration of the Veteran’s reports of shortness of breath since service, which the Board finds not credible for the reasons discussed above. The examiner also considered the chest X-rays showing no active disease from 2001 to 2010 and other medical records consistent with those summarized by the Board above. This opinion has high probative value because it considered the Veteran’s history consistent with the Board’s credibility findings and includes a rationale. The January 2016 examiner noted that the Veteran was reported respiratory symptoms at his 1971 entrance examination and was diagnosed with a URI, and that he was diagnosed with acute bronchitis in 1972. The examiner stated that the records did not document chronic, ongoing treatment for bronchitis. The examiner noted that there was no respiratory diagnosis from 2002 to 2010 and that the Veteran reported using an albuterol inhaler as needed, but not in several months. This examiner did not provide a true etiology opinion for the Veteran’s condition, but these notations are consistent with the Board’s review and credibility findings. Additionally, although the Veteran asserted in a February 2016 correspondence that the January 2016 examiner distorted the facts by stating that he had respiratory symptoms in 1971 that actually occurred in 1972, the Veteran did report respiratory symptoms in his 1971 entrance examination as well as in 1972. The June 2017 examiner noted a diagnosis of chronic bronchitis since 1972 and restrictive lung disease due to obesity since June 2017. A report of pulmonary function tests (PFTs) for this examination noted an interpretation of restrictive disease. The examiner stated that the Veteran reported a history of shortness of breath since his 1971 entrance examination, and medical records reflected a complex history of multiple episodes of respiratory problems and diagnoses, including those noted on the 1971 entrance examination, and diagnoses of bronchitis and shortness of breath several times in 1972. The examiner also stated that pulmonary function testing in May 2013 showed a poor effort with some minimal changes, and chest X-rays from 2001 to 2010 were negative, with no evidence of changes consistent with restrictive or obstructive lung disease. The Veteran currently used Mucinex as needed for mucus and congestion, and he reported bronchitis symptoms that occurred seasonally and required antibiotics about three times per year. The examiner opined that the Veteran’s current condition was less likely than not incurred in or caused by service. He reasoned that medical records were consistent with bronchitis that likely existed prior to service and was officially diagnosed early in service, and the in-service symptoms were likely the same symptoms that were recurrent in the present day. He stated that nothing in the medical records suggested aggravation of the condition during service. This examiner’s opinion has low probative value because it was based, in part, on the Veteran’s reports of ongoing shortness of breath since 1971, which the Board has found not credible. Additionally, this examiner did not mention the lack of respiratory complaints from 2001 to 2010 or explanations by the 2013 examiner, as well as a subsequent August 2017 examiner, that acute bronchitis is usually bacterial or viral and the one episode during service did not show chronicity. The August 4, 2017 examiner opined that it was less likely than not that the Veteran’s claimed condition began in or is otherwise the result of service. The examiner stated that medical literature defines bronchitis as inflammation of the airway, and acute and chronic bronchitis are differentiated by etiologies, pathologies, and therapies. Specifically, acute bronchitis is often caused by infection through virus or bacteria. This is similar to the notation by the 2013 VA examiner. Chronic bronchitis is characterized by a productive cough that lasts for three months or more per year for at least two years and most often develops due to recurrent injury of the airways caused by inhaled irritants. Bronchiectasis refers to an irreversible airway dilation that involves the lung in either a focal or diffuse manner and is classically categorized as tubular, varicose, or cystic. The examiner noted the June 2017 examiner’s opinion that the Veteran’s bronchitis likely existed prior to service based on the reports at the 1971 entrance examination. However, this examiner disagreed and opined that there was no indication of a diagnosis of acute or chronic bronchitis or bronchiectasis at the entrance examination. The August 4, 2017 examiner reviewed the Veteran’s treatment episodes during service and noted that at separation in 1973 the upper respiratory examination was normal and there were no reported complaints, diagnosis, injury, or events related to chronic bronchitis or bronchiectasis. The examiner stated that the Veteran’s in-service presentations were acute, self-limited, and transient viral syndromes and/or common cold, with a single event related to a resolved acute bronchitis without chronicity or continuity of chronic bronchitis or bronchiectasis. This is similar to the notation by the 2016 examiner. This opinion has high probative value because it considered the Veteran’s history consistent with the Board’s credibility findings and includes a rationale based on application of medical literature and expertise. The August 15, 2017 examiner opined that the Veteran most likely came into service with a history of bronchitis, based on his reference to respiratory issues at his entrance examination, and left with the same diagnosis. However, the examiner stated that the Veteran had acute bronchitis during service and there was no exacerbation of his symptoms during service, explaining that the Veteran had self-limited viral or bacterial illnesses that resolved with time. The examiner noted intermittent episodes of bronchitis over the years and a past history of smoking. This opinion has low probative value because it does not reflect consideration of the medical differences between acute and chronic bronchitis and other types of respiratory conditions as noted by the August 4, 2017 examiner, based on medical literature, or the significance of resolution of the illnesses during service. In an April 2018 letter (labeled “other”), the Veteran asserted that VA contract examiners are biased against veterans, but he has not identified any support for this assertion, and there is no indication of bias in this case. The Veteran further asserted that examiners improperly found that he had a respiratory illness prior to service. As explained above, the Veteran did report various respiratory symptoms at his entrance examination; however, he is presumed sound for any respiratory or pulmonary condition, and that presumption has not been rebutted. For the reasons stated above, the April 2013 and particularly the August 4, 2017 VA examiners’ opinions are the most probative and persuasive as to whether there is a relationship between any current condition and the Veteran’s service. These opinions include a rationale that reflects application of medical expertise, including relevant medical literature, to the Veteran’s accurate factual and medical history, consistent with the Board’s credibility findings herein. These opinions outweigh the other opinions of record and establish that the Veteran’s current respiratory or pulmonary conditions are not related to his symptoms or diagnoses during service. As discussed above and incorporated herein, the evidence also does not establish that a current pulmonary or respiratory disability is due to any in-service exposure to herbicide agents, lead paint or poisoning, or radiation, or that it began in combat. In summary, the preponderance of the evidence is against finding that a current pulmonary or respiratory disability is related to service under any reasonably raised theory. There is no reasonable doubt to resolve, and the appeal is denied. 3. , 4., 5., 6., 7., 8., and 9. Service connection for cervical spine, lumbar spine, bilateral shoulder, bilateral hip, bilateral knee, and bilateral ankle disabilities The Veteran asserts that he has arthritis or gout of the cervical spine, lumbar spine, shoulders, hips, knees, and ankles due to exposure to herbicide agents, lead paint, radiation, and/or combat, which are discussed above, and that his arthritis began within one year after service. See, e.g., 2011 and 2014 hearing transcripts. The Board first concludes that the Veteran does not have a current left hip disability and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In this regard, although the Veteran is competent report noticeable symptoms such as hip pain, he is not competent to provide a diagnosis for his pain, as this requires interpretation of medical tests and imaging. Jandreau, 492 F.3d at 1377. There is no left hip diagnosis in VA or private treatment records, and the two August 2017 VA examiners noted that there was right hip arthritis but no left hip diagnosis. The August 4, 2017 examiner specified that there was no left hip pathology. A disability may be shown without an underlying diagnosis if there is pain that results in functional impairment of earning capacity. Saunders v. Wilkie, 886 F.3d 1356, 1368 (Fed. Cir. 2018). However, there is no argument or indication that the Veteran’s left hip condition, including pain, impairs his ability to work or otherwise impairs his earning capacity. Although the Board presumes that he has some degree of left hip pain or other noticeable symptoms because he is seeking service connection, he has not identified any functional impairment due to such symptoms. There is no indication of impairment of earning capacity due to the left hip in treatment records during the appeal period. Private treatment records in November 2002 reflect complaints of right hip pain, and a March 2005 private record from Dr. N opined that the Veteran’s right hip and other conditions, but not the left hip, prevented him from working as a psychiatric technician. In an October 2009 VA treatment record, the Veteran complained of right hip pain, but not left hip pain. During the 2014 Board hearing, he referred to his singular “hip.” During the January 2016 VA examination, he reported pain in his right hip only and denied left hip pain for the last years. The August 15, 2017 examiner further noted that there was no impact from the Veteran’s hips on his ability to work. He reported working most recently as a social worker in a hospital. Therefore, a disability is not established based on pain without a diagnosis. As there is no current disability, service connection may not be granted for a left hip condition. Additionally, the Board concludes that the chronic disease presumption does not apply, and there is no direct link to service. Although the Veteran has current arthritis of the cervical spine, lumbar spine, bilateral shoulders, right hip, bilateral knees, and bilateral ankles, which is a chronic disease under 38 C.F.R. § 3.309(a), it was not noted or diagnosed as chronic during service, it did not manifest to a compensable degree within one year after service, and chronicity or continuity of symptomatology is not established. The evidence also does not establish a direct nexus between the current disabilities and an in-service injury, event or disease. Concerning a current disability, the August 15, 2017 VA examiner diagnosed degenerative arthritis in the Veteran’s cervical spine (neck), lumbar spine (back), bilateral shoulders, right hip, bilateral knees, and bilateral ankles. This is generally consistent with the VA and private treatment records during the appeal period. In addition, a November 2002 private MRI showed a right knee meniscal tear. The Veteran also reported being diagnosed with gout about 15 years ago during the August 15, 2017 VA examination, stating that it mainly affected his big toes. A November 2006 VA treatment record noted a possible diagnosis of gout when the Veteran reported that his private provider told him he had gout. A March 2008 VA record then noted a prescription for gout, and October 2008 records noted a diagnosis of gout with elevated uric acid but no flares for a few months. In December 2008, the Veteran reported left foot pain and swelling and that he had gout for “several years” with a flare-up about three weeks earlier. An April 2009 VA treatment record noted gouty arthritis. However, a January 2016 VA examiner noted the Veteran’s report of gout since 2004, but she stated that X-rays showed degenerative joint disease and no active gout. The August 4, 2017 VA examiner also explained that X-rays were not consistent with gouty arthritis for the claimed joints, including the ankles. These opinions are more probative and outweigh the notation of gouty arthritis in the VA treatment record because they include a rationale based on review of X-rays. Thus, although there has been gout in the Veteran’s feet at times during the appeal period, he has not claimed a foot condition, and he does not have gout or gouty arthritis in his ankles or other joints. Concerning a nexus to service, the Board initially notes that there are some suggestions of a preexisting condition for the lumbar spine. During his February 1971 service entrance examination, the Veteran reported a history of back trouble, and the examiner noted a history of back strain. However, the Veteran’s spine was evaluated as clinically normal and no active lumbar spine condition was noted. Thus, the entrance examination reflects only a history of conditions, not a current condition, and he is presumed in sound condition at entry. 38 C.F.R. § 3.304(b). VA has not met its burden to rebut this presumption. There are contemporaneous findings that the Veteran’s spine was clinically normal at induction and at his January 1973 separation examination, and no VA examiner has opined that a lumbar spine disability clearly and unmistakably existed prior to service. As the presumption of soundness has not been rebutted, the general service connection requirements apply, and service connection will be granted if the evidence shows that the current disability began during or is otherwise related to service. To the extent the Veteran asserts that he has had noticeable joint or musculoskeletal symptoms continuously since service or within one year after service, the Board finds these reports are not credible due to inconsistency with other more probative evidence in the record. First, the Veteran has given internally inconsistent reports as to the date of onset or injury for his claimed conditions. In a June 2007 VA claim that included arthritis and the knees, back, and neck, he asserted that his “injury happen[ed]” during service while aboard the ship, but he did not identify a date of onset of the disability or treatment. He then wrote “[a]ll disabilities due to exposure”; this does not suggest symptoms or an actual injury during service. During the 2011 Board hearing, the Veteran asserted that he has had limitations since 1973 due to arthritis in his knees, back, and neck. He reported having his first knee surgery in 1991 and that he treated his condition with over-the-counter medications from 1973 to 1991. He was discharged from service in February 1973. In a July 1998 VA claim (also received in August 2001), the Veteran asserted that his arthritis began in 1992, referencing knee surgeries. Another claim form associated with the file in September 2009 identified arthritis as beginning in 1992. In his July 2001 claim, the Veteran stated that his arthritis began in 1986 and that he had a neck and shoulder injury in 1986. In a May 2013 substantive appeal (VA Form 9), the Veteran identified private treatment from Dr. N for arthritis in the knees and neck for 20 years, or since approximately 1993. During his 2014 Board hearing, the Veteran specified that he thinks his bilateral knee problems are due to service, but he did not experience knee problems during service or shortly thereafter. He had problems over the years and was first diagnosed in the early 1980s. The Veteran further testified that he was first treated and diagnosed with a neck condition in the early 1980s, and he did not have any in-service neck injury. He asserted that his arthritis conditions in the neck, shoulders, back, hip, knees, and ankles are due to herbicide or lead paint exposure in service. During the August 15, 2017 VA examination, the Veteran asserted that he twisted his ankles during service. He denied any back injury during service and reported that his back started bothering him after service. He further reported that he had knee injuries in the 1990s and was followed by workman’s compensation. The Veteran also reported that he developed neck pain in the late 1990s. In an April 2018 correspondence (labeled “other”), the Veteran again asserted that herbicide exposure caused his joint problems, although he stated that he has had continued treatment for all conditions since service to the present. As the above reports as to the date of onset or injury are internally inconsistent, they have low probative value. These are more than minor inconsistencies, as the Veteran gave dates ranging from 1973 to the 1980s to the 1990s for when his symptoms, diagnosis, and treatment began. Moreover, he generally identified the date of onset of his symptoms as several years after service, including when he gave more detail in the 2014 Board hearing and 2017 VA examination. This directly contradicts his other reports of symptoms within one year after service. Additionally, the Veteran’s service records do not reflect any complaints, treatment, or diagnoses for the cervical spine, lumbar spine, shoulders, hips, knees, or ankles, and his January 1973 separation examination was clinically normal for all joints. Thus, even if the Veteran had an undocumented episode of twisting his ankles during service, there is no indication of any lasting symptoms or disability. Notably, post-service treatment records reflect work injuries to many of the Veteran’s claimed joints, and the records are consistent with the Veteran’s identification of symptoms and treatment beginning the late 1980s and/or 1990s. For the cervical spine, a November 1995 private treatment record reflects that the Veteran injured his neck during a car crash. Private records in August and November 1999 noted neck and shoulder pain since a September 1998 injury. Similarly, a November 2000 record from Dr. N stated that the Veteran sustained a neck injury in September 1998 and opined that the neck injury was work-related. In a July 2001 report for his SSA claim, the Veteran also reported that his neck problems began in September 1998. In a November 2001 private record, he again reported injuring his neck in 1998 at work. In a March 2002 VA treatment record, the Veteran reported off and on pain in the neck since 1998. In November 2003 and April 2004 private records, he reported neck pain since a work accident in October 2002. The diagnosis in April 2004 was degenerative disc disease at the C6-7 level. A July 2004 VA treatment record noted degenerative joint disease of the neck. In a November 2005 VA record, the Veteran reported neck pain and tingling of the fingertips for three years. In a February 2006 private record, Dr. N diagnosed myofascial pain syndrome for the Veteran’s neck complaints. For the lumbar spine, a September 1988 private record reflects that the Veteran hurt his back on the job in August 1988. The diagnosis was back strain. Private records in April 2004 note reports of pain in the back and leg that began after an October 2002 work accident, and a diagnosis of lumbar syndrome or strain. The Veteran denied problems with his back prior to this work injury. In September 2005, X-rays conducted by VA showed degenerative changes of the thoracic spine. For the shoulders, a November 1995 private treatment record reflects that the Veteran reported injuring his left shoulder in a car crash. A November 1998 private record reflects that the Veteran injured his shoulder at work in September 1988 and had a possible full thickness rotator cuff tear based on an MRI. An August 1999 private record again noted neck and shoulder symptoms since a September 1998 accident. Private records in November 1999 noted pain in the neck and shoulders that was part of an original injury in September 1998, and that neck pain that was still radiating into the shoulders was possibly due to cervical spine pathology. A January 2000 private record noted that the Veteran had left shoulder surgery in December 1998 but that his degenerative changes to the acromioclavicular joint existed prior to the September 1998 work accident. Private records in April and July 2001 noted a left shoulder date of injury in May 1992. For the right hip, private records from Dr. N in November 2002 noted complaints of right knee and hip pain when several large individuals fell on him at work in October 2002. An MRI was unremarkable. Private records in November 2003 and April 2004 reflect right hip pain since a work accident in October 2002. Although an April 2004 record noted that a November 2002 MRI showed right hip significant arthritic process, that is inconsistent with the November 2002 record. Moreover, this was nearly 30 years after then Veteran’s service discharge. For the knees, May 1992 private records from Dr. N noted bilateral knee pain after a work injury in May 1992 and a diagnosis of left knee injury and right knee torn meniscus, patella fracture, and anterior cruciate ligament (ACL) injury. A June 1993 private record noted a left knee torn meniscus with a date of injury as May 1992. A July 1998 record from Dr. N again noted that the Veteran sustained bilateral knee injuries in May 1992 and continued to have pain after that time, and Dr. N opined that all symptoms in both knees were related to the May 1992 injury. In a July 2001 report for his SSA claim, the Veteran reported that his knee problems began in September 1998. Private records in April, July, and November 2001 and again in May 2002 noted a right knee date of injury in May 1992. Private records from Dr. N in November 2002 then noted that the Veteran had right knee pain when several large individuals fell on him in October 2002. Although the pain was mostly in his hip at first, it progressed to his knee within 24 hours. An MRI showed a right knee meniscal tear. In December 2002, the Veteran underwent a right knee arthroscopy, and he reported three knee surgeries from 1992 to 1994. Private records in November 2003 and April 2004 reflect complaints of right knee pain since a work accident in October 2002, and the April 2004 record noted that the right knee was aggravated by this accident. For the ankles, VA treatment records in March 2005 noted reports of left ankle pain and swelling for one month or left ankle arthralgia. An X-ray of the left ankle and foot showed sequela from an old injury and degenerative changes of the first metatarsophalangeal (MTP) joint. There was no identification as to the date of the old injury, and this was more than 30 years after service. A September 2005 VA record then noted ankle degenerative joint disease. The January 2016 VA examiner diagnosed degenerative arthritis in both ankles, with intermittent pain and swelling. The Veteran’s above reports for medical treatment are generally consistent with each other. These reports are highly probative as to the nature and timing of his conditions because they are contemporaneous in time to the actual symptoms and he had an incentive to report an accurate history in order to receive proper care. It is reasonable to assume that the Veteran would have reported a history of noticeable joint symptoms that were present since service or prior to his work injuries when he sought treatment if they existed at those times. Instead, he expressly identified his pain and other symptoms as starting after the work injuries. The Veteran’s reports for treatment directly contradict his recollection, at times, for his VA claim of having symptoms since service. The medical records are more probative and outweigh his contrary reports. Thus, the Board finds the Veteran not credible as to having had ongoing symptoms in the cervical spine, lumbar spine, shoulders, hips, knees, or ankles since service or within one year after service. To reach the compensable level to trigger the chronic disease presumption, arthritis must be manifested by pain, with or without compensable limitation of motion. See 38 C.F.R. §§ 4.59, 4.71a, Diagnostic Code 5003. As discussed above, arthritis was not diagnosed until years after service, and the most probative evidence does not establish pain in any of the Veteran’s claimed joints during service or within one year after service, by February 1974, or continuous symptoms thereafter. Therefore, the chronic disease presumption does not establish service connection for any of these disabilities. 38 C.F.R. §§ 3.303(b), 3.307(a), 3.309(a)(3). Concerning a direct link, the Veteran is not competent to provide an opinion as to whether his current joint conditions are related to service. This is a medically complex question that requires knowledge of the musculoskeletal system and interpretation of the Veteran’s medical history. Jandreau, 492 F.3d at 1377. The medical evidence does not establish a link between the Veteran’s current arthritis and service. The Veteran submitted private medical opinions from Dr. N in January 2011 and June 2013, which state that the Veteran’s arthritis in the cervical spine, lumbar spine, and bilateral knees are due to service. Both of these letters indicate that this opinion is based on the Veteran’s report that he has had symptoms since active service and that he did not have symptoms prior to service. This rationale is based on an inaccurate factual premise, as the Board finds the Veteran not credible as to having had symptoms since service or within the one year after service. Dr. N provided no other rationale. Additionally, Dr. N did not address the Veteran’s post-service injuries, even though he treated the Veteran for those injuries. See, e.g., private records in October 1988, September 1993, July 1998, November 2000, July 2001, and April 2004. Furthermore, Dr. N previously opined that the Veteran’s bilateral knee symptoms were related to a May 1992 injury, see July 1998 private record; that his neck pain originated from a September 1998 injury, see November 2000 private record; and that his back, neck, leg, and arm pain were related to an October 2002 work accident, see April 2004 private record. Therefore, the Board finds that Dr. N’s 2011 and 2013 opinions have no probative value and are outweighed by the other evidence. During the 2011 Board hearing, the Veteran asserted that Dr. N told him that his arthritis was due to herbicide exposure in service or because his bones were not getting enough oxygen due to his breathing problems or bronchitis. Although the Veteran is competent to report his recollection of what his provider told him, the medical records from Dr. N do not reflect any such opinions. Instead, they reflect that the Veteran’s conditions were attributed to post-service work injuries. Additionally, there is no indication of any rationale for any other opinions. Moreover, as discussed above, the evidence does not show herbicide exposure during service, and service connection for the Veteran’s pulmonary or respiratory condition is denied. These reports by the Veteran have low probative value and are outweighed by the other evidence. In contrast, several VA examiners addressed the nature and etiology of the current conditions based on a review of the claims file in addition to the Veteran’s reports. The January 2016 examiner opined that the claimed arthritis conditions were less likely than not related to service. The examiner stated that the Veteran’s entrance examination noted back strain, but there was no evidence of any musculoskeletal condition or gout during service, and the Veteran’s exit examination was normal for orthopedic conditions. There was also no evidence of arthritis within one year of discharge from service, and most X-rays showed degenerative joint disease and no active gout. The examiner further noted post-service work-related conditions affecting the Veteran’s cervical spine, right knee, right hip, and low back. The August 4, 2017 examiner also opined that it was less likely than not that any of the Veteran’s claimed conditions, including degenerative joint disease or arthritis, gout, or gouty arthritis, were related to service. The examiner cited the Veteran’s treatment records as well as medical research in support of this conclusion, including noting the absence of complaints in service records, symptoms after post-service injuries, and that X-rays were not consistent with gouty arthritis. The August 15, 2017 examiner also opined that it was less likely than not that the current disabilities were related to service. The examiner noted that the Veteran did not have any neck, back, shoulder, hip, knee, or ankle problems in service and had a normal orthopedic examination upon separation from service. There was no evidence of any joint issues until years after service, the Veteran had later work-related injuries to his joints, and he was found to have degenerative joint disease in various joints when he was much older. The examiner opined that the Veteran’s findings were expected due to his injuries after service, as well as being male, obese, and his age. He had complaints after he left service and now had classic age-related degenerative changes in his joints, on top of the post-service injuries. The examiner also noted the post-service diagnosis of gout but opined that gout was due to over production of uric acid, not herbicide exposure or lead exposure. These opinions are highly probative because they include a rationale that reflects application of medical expertise to the Veteran’s accurate factual and medical history, consistent with the Board’s credibility findings herein. They outweigh the other opinions of record and establish that the Veteran’s current cervical spine, lumbar spine, bilateral shoulder, right hip, bilateral knee, and bilateral ankle disabilities are not related any disease, injury, or event during service. In an April 2018 letter (labeled “other”), the Veteran asserted that VA contract examiners are biased against veterans, but he has not identified any support for this assertion, and there is no indication of bias in this case. As discussed above and incorporated herein, the evidence also does not establish that the claimed conditions are due to any in-service exposure to herbicide agents, lead paint or poisoning, or radiation, or that they began in combat. In summary, the preponderance of the evidence is against finding that the current cervical spine, lumbar spine, bilateral shoulder, right hip, bilateral knee, or bilateral ankle disabilities are related to service under any reasonably raised theory. There is no reasonable doubt to resolve, and the appeal is denied. 10. Service connection for drug or medication dependency The Veteran asserts that he is entitled to service connection for drug or medication dependency on a secondary basis, in that he is addicted to or is required to take drugs or medications in order to function due to his other claimed service-connected conditions. See, e.g., August 2014 hearing transcript. The Board concludes that the Veteran has not had a diagnosis of drug or medication dependency recent in time or during the pendency of his claim. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Moreover, the competent evidence does not show a secondary relationship to his service-connected disabilities. 38 C.F.R. § 3.310. In an August 2015 remand, the Board directed the AOJ to schedule the Veteran for a VA psychiatric examination for his claimed drug/medication dependency. The Veteran was scheduled for such an examination in October 2017, but he refused the examination, stating that he was not sure he filed a claim for a mental disorder. The AOJ then contacted the Veteran via telephone in November 2017 and explained that the psychiatric examination was for his claimed drug/medication dependency, and the Veteran agreed to attend VA psychiatric examination. The AOJ scheduled a new VA examination in December 2017, but the Veteran cancelled this rescheduled examination, as noted in a January 2018 compensation and pension exam inquiry. Neither the Veteran nor his representative has presented good cause for his failure to report for the VA examination, requested another examination, or argued that he did not receive notice of the VA examination after receipt of the January 2018 Supplemental Statement of the Case (SSOC). Therefore, the Veteran failed to report for the VA examination without good cause. Where entitlement to a benefit cannot be established or confirmed without a current VA examination and the Veteran fails to report for an examination scheduled in conjunction with an original compensation claim without good cause, the claim shall be rated based on the evidence of record. 38 C.F.R. § 3.655(a)-(b). Furthermore, VA’s duty to assist a claimant is not a one-way street, and the Veteran has failed to cooperate in the development of his claim. Wood v. Derwinski, 1 Vet. App. 406 (1991). Under the circumstances of this case, there is no duty to attempt to provide another examination or medical opinion, and there has been substantial compliance with the Board’s prior remand directives. Although the Veteran believes he is dependent on drugs or medication a result of his service-connected disabilities, he is not competent to provide a diagnosis for this condition or an opinion as to whether it is due to his service-connected disabilities. These are medically complex questions that require knowledge of the interactions between organ systems in the body and interpretation of the Veteran’s medical and psychiatric history. Jandreau, 492 F.3d at 1377. The available medical records do not establish these elements. For example, a May 2012 VA treatment record noted that there was no active abuse or dependence, and a May 2017 record noted no substance abuse. Although treatment records, such as in February 2016, note alcohol dependence, they do not note drug or medication dependence. The Veteran also asserted in a May 2013 VA Form 9 that his drug abuse is a symptom of PTSD. He is not service-connected for a mental health disorder. In a June 2019 brief, the Veteran’s representative referenced service personnel records mentioning him using hashish during service. The Veteran has also asserted that he has used unspecified drugs continuously since 1972. See, e.g., July 1998 claim (also received August 2001); February 2009 VA Form 9. Service connection cannot be awarded where a disability is based on the Veteran’s willful misconduct, to include drug abuse or addiction or the use of drugs to enjoy their intoxicating effects. 38 U.S.C. § 105(a); 38 C.F.R. §§ 3.1(m), 3.301(a), (c), (d). Moreover, the Veteran reported a drug or narcotic habit at his February 1971 service entrance examination, which was noted as heroin use. The criteria for service connection for drug abuse or medication dependency are not met. There is no reasonable doubt to resolve, and the appeal is denied. TDIU 11. Entitlement to a TDIU The Veteran contends that he is unemployable due to his claimed disabilities. TDIU will be granted where the schedular rating is less than 100 percent if the Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Generally, a schedular percentage threshold must be met to be eligible for TDIU; if there are two or more service-connected disabilities, at least one disability must be rated at 40 percent or more and the combined rating must be 70 percent or more. However, an extraschedular TDIU may be awarded after referral to the Director of Compensation Services if the evidence shows the Veteran is unemployable due to service-connected disabilities. Consideration should be given to prior education, training, and work experience, but not to age or impairment from nonservice-connected disabilities. See 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.19; see also Gleicher v. Derwinski, 2 Vet. App. 26 (1991); Pederson v. McDonald, 27 Vet. App. 276 (2015). The sole fact that a claimant is unemployed or has difficulty obtaining employment is not enough; the question is whether the Veteran is capable of performing the physical and mental acts required by employment. Smith v. Shinseki, 647 F.3d 1380, 1385 (Fed. Cir. 2011). All reasonable doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Veteran’s current service-connected disabilities are tinnitus rated as 10 percent since July 20, 2007, and left ear hearing loss rated as noncompensable since July 20, 2007, for a combined evaluation of 10 percent since July 20, 2007. Therefore, he does not meet the schedular criteria for TDIU under 38 C.F.R. § 4.16(a). The evidence also does not show unemployability due to service-connected disabilities to warrant an extraschedular referral under 38 C.F.R. § 4.16(b). In a TDIU application (VA Form 21-8940) received in May 2013, the Veteran asserted that his hearing loss, hypertension, arthritis, and pulmonary disabilities prevented him securing or following any substantially gainful occupation. In a VA Form 21-8940 received in April 2014, he identified arthritis as preventing his employment. In disability reports and an appeal for his SSA claim, the Veteran asserted that his left ear hearing loss, tinnitus, hypertension, gout, arthritis or knee, neck, back, hip problems limited his ability to work since 2008. In a 2010 decision, the SSA found the Veteran disabled due to his right knee disability, neck disability, gout, and hypertension. Of these conditions, only left ear hearing loss and tinnitus are service-connected. Concerning the Veteran’s occupational and educational history, he reported in his TDIU applications and for his SSA claim that he last worked in 2008 and that his prior positions were as a social worker in a hospital. In a 2017 VA examination, he reported working in a factory after service for eight years and then going to school for social work and working as a social worker since that time. In his SSA disability report, the Veteran reported completing three years of college. The Veteran identified duties in his prior social worker positions of computer data entry, observing patients, caring for adults with psychiatric conditions, physical retraining, taking blood pressure, and “care giver.” He reported sitting for seven hours a day and less than an hour per day of walking, standing, and reaching. Despite the Veteran’s assertion that his hearing loss and tinnitus affects his ability to be employed, he has not described how these conditions would prevent the types of activities he performed. In a functional report for his SSA claim, he reported being limited in standing, walking, and other primarily physical activities. There is no other suggestion that tinnitus or left hearing loss would prevent substantially gainful employment for a social worker or similar position consistent with his history. A January 2009 SSA field examiner and February 2009 SSA examiner found that the Veteran had no hearing limitations. An April 2013 VA examiner stated that neither left ear hearing loss nor tinnitus had any impact on the Veteran’s ability to work. A November 2017 VA examiner also noted that there was no evidence to showing that hearing loss resulted in occupational limitations. The Board finds these opinions persuasive; they reflect that the Veteran’s symptoms of service-connected disabilities did not prevent him from securing or following substantially gainful employment. There is no contrary medical opinion of record. The SSA found the Veteran disabled as of March 2010 due to his nonservice-connected right knee disability, neck disability, gout, and hypertension. Although the Board is remanding the claim of service connection for right ear hearing loss for an updated opinion as to the etiology of the condition, there is no indication that any information obtained upon remand will affect the TDIU claim. As noted above, the evidence does not reflect that the Veteran’s hearing loss in either ear prevents him from working consistent with his prior history. Therefore, even if service connection is granted for right ear hearing loss, the addition of the effects of this disability would not result in a finding of unemployability. In summary, the evidence does not support a finding that the Veteran’s service-connected disabilities prevent him from securing or maintaining substantially gainful employment consistent with his educational and occupational history. The criteria for a TDIU are not met. There is no reasonable doubt to resolve, and the appeal is denied. REASONS FOR REMAND 1. Service connection for right ear hearing loss is remanded In June 2019, the Veteran’s representative submitted arguments concerning his right ear hearing loss based on medical literature as to delayed onset hearing loss that may not have been considered by the VA examiner, including a 2018 report that post-dated the examination. This literature is insufficient to establish service connection, but it may be combined with a medical opinion based on the facts of the Veteran’s case. Therefore, a remand is necessary for a new medical opinion. The matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s right ear hearing loss was at least as likely as not related to in-service noise exposure. The examiner should consider the additional medical literature contained in the June 2019 appellate brief regarding delayed onset for hearing loss, as applied to the facts of the Veteran’ case. The examiner should explain the reasons behind any opinions and conclusions reached. The examiner is reminded that the term “as likely as not” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Wheatley The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.