Citation Nr: 20004083 Decision Date: 01/16/20 Archive Date: 01/16/20 DOCKET NO. 16-22 297 DATE: January 16, 2020 ORDER Entitlement to an evaluation in excess of 10 percent for right iliotibial band syndrome is dismissed. Entitlement to an evaluation in excess of 10 percent for left iliotibial band syndrome is dismissed. Entitlement to service connection for hearing loss is dismissed. Entitlement to service connection for temporomandibular joint (TMJ) disability is dismissed. Entitlement to a compensable evaluation for headaches is denied prior to October 10, 2019 Entitlement to an evaluation of 30 percent for headaches is granted from October 10, 2019. Entitlement to service connection for a left foot disability is denied. Entitlement to service connection for a right foot disability is denied. Entitlement to service connection for a left ankle disability is denied. Entitlement to service connection for a left hand disability is denied. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a left shoulder disability is denied. REMANDED Entitlement to a compensable evaluation for abdomen scars is remanded. FINDINGS OF FACT 1. During the August 2019 hearing before the undersigned, as well as in a letter received in August 2019, the Veteran indicated, along with his representative, his wish to withdraw the claims of entitlement to evaluations in excess of 10 percent for left and right iliotibial band syndrome, and entitlement to service connection for hearing loss and for TMJ dysfunction. 2. Prior to October 10, 2019, the Veteran’s service-connected headaches were not manifested by characteristic prostrating attacks of any duration. 3. From October 10, 2019, the Veteran’s headache disability reflects characteristic prostrating attacks occurring on an average once a month over last several months. 4. The Veteran does not have a currently diagnosed left foot disorder. 5. The Veteran does not have a currently diagnosed right foot disorder. 6. The Veteran does not have a currently diagnosed left ankle disability. 7. The Veteran does not have a currently diagnosed left hand disability. 8. The Veteran’s low back disability did not have clinical onset in service or within one year of service separation and is not otherwise related to active duty. 9. The Veteran’s left shoulder disability did not have clinical onset in service or within one year of service separation and is not otherwise related to active duty. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the claim for entitlement to an evaluation in excess of 10 percent for right iliotibial band syndrome by the appellant have been met. 38 U.S.C. § 7105(b)(2), (d)(5); 38 C.F.R. § 20.204. 2. The criteria for withdrawal of the claim for entitlement to an evaluation in excess of 10 percent for left iliotibial band syndrome by the appellant have been met. 38 U.S.C. § 7105(b)(2), (d)(5); 38 C.F.R. § 20.204. 3. The criteria for withdrawal of the claim for entitlement to service connection for hearing loss by the appellant have been met. 38 U.S.C. § 7105(b)(2), (d)(5); 38 C.F.R. § 20.204. 4. The criteria for withdrawal of the claim for entitlement to service connection for TMJ disability by the appellant have been met. 38 U.S.C. § 7105(b)(2), (d)(5); 38 C.F.R. § 20.204. 5. The criteria for a compensable rating for service-connected headaches were not met prior to October 10, 2019. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8100 (2018). 6. The criteria for a 30 percent rating, but no higher, for headaches have been met from October 10, 2019. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.124a, Diagnostic Code 8100. 7. The Veteran does not have a left foot disability that was incurred or aggravated in service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 8. The Veteran does not have a right foot disability that was incurred or aggravated in service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 9. The Veteran does not have a left ankle disability that was incurred or aggravated in service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 10. The Veteran does not have a left hand disability that was incurred or aggravated in service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 11. The Veteran does not have a low back disability that was incurred or aggravated in service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 12. The Veteran does not have a left shoulder disability that was incurred or aggravated in service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2008 to June 2012. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an October 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. Withdrawn Appeals 1. Entitlement to an evaluation in excess of 10 percent for right iliotibial band syndrome is dismissed. 2. Entitlement to an evaluation in excess of 10 percent for left iliotibial band syndrome is dismissed. 3. Entitlement to service connection for hearing loss is dismissed. 4. Entitlement to service connection for a TMJ disability is dismissed. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by a veteran or by his or her authorized representative. Id. During the August 2019 hearing before the undersigned, the Veteran indicated, along with his representative, his wish to withdraw the claims of entitlement to evaluations in excess of 10 percent for right and left iliotibial band syndrome, and entitlement to service connection for hearing loss and for TMJ dysfunction. In a letter received on August 30, 2019, subsequent to the Veteran’s hearing and prior to the promulgation of a decision in the appeal, the Veteran stated that he wished to withdraw the above-identified claims on appeal. This withdrawal was done both in sworn testimony and in writing. There thus remain no allegations of errors of fact or law for appellate consideration as to the issues identified on the title page, above. Accordingly, the Board does not have jurisdiction to review these claims, and they are dismissed. Increased Rating Disability ratings are determined by applying a schedule of ratings that is based on average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Each disability must be viewed in relation to its history and the limitation of activity imposed by the disabling condition should be emphasized. 38 C.F.R. § 4.1. Examination reports are to be interpreted in light of the whole recorded history, and each disability must be considered from the point of view of the appellant working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). It is the responsibility of the rating specialist to interpret reports of examination in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2 (2018). Consideration of factors wholly outside the rating criteria constitutes error as a matter of law. Massey v. Brown, 7 Vet. App. 204, 207-08 (1994). Evaluation of disabilities based upon manifestations not resulting from service-connected disease or injury and the pyramiding of ratings for the same disability under various diagnoses is prohibited. 38 C.F.R. § 4.14 (2018). It is the policy of VA to administer the law under a broad interpretation, consistent with the facts in each case with all reasonable doubt to be resolved in favor of the claimant. However, the reasonable doubt rule is not a means for reconciling actual conflict or a contradiction in the evidence. 38 C.F.R. § 4.3 (2018). 5. Entitlement to a compensable evaluation for headaches prior to October 10, 2019, is denied. 6. Entitlement to a 30 percent evaluation for headaches from October 10, 2019, is granted. The Veteran’s headache disability has been assigned a noncompensable evaluation under Diagnostic Code 8100, which pertains to migraine headaches. 38 C.F.R. § 4.124a (2018). Under Diagnostic Code 8100, a 10 percent rating is warranted for migraines with characteristic prostrating attacks averaging one episode in 2 months over the last several months. A 30 percent rating is warranted for headaches with characteristic prostrating attacks occurring on an average once a month over the last several months. The maximum schedular disability rating of 50 percent is warranted for migraine headaches with very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability. The rating criteria do not define “prostrating,” nor has the Court. Fenderson v. West, 12 Vet. App. 119 (1999). According to Dorland’s Illustrated Medical Dictionary 1531 (32nd ed. 2012), “prostration” is defined as “extreme exhaustion or powerlessness.” The Board has reviewed the evidence of record, including the VA examination report, VA treatment records, and the Veteran’s lay statements. In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is entitled to a compensable rating of 30 percent for his headache disorder, effective from October 10, 2019. Prior to that date, a noncompensable rating is warranted. During the period prior to October 10, 2019, there are several VA examinations of record addressing the Veteran’s claimed headache disability. The Veteran was afforded an initial VA examination in July 2012. Thereafter, he was afforded VA headache examinations in January 2016 and in March 2017. Pertinently, while the Veteran generally and credibly reported headache symptoms including pain, sensitivity to light and sensitivity to sound, all three examiners indicated that the Veteran did not have characteristic prostrating attacks of migraine or non-migraine headache pain. For the period prior to October 10, 2019, there is no other pertinent evidence of record, or any evidence which indicates that the Veteran had any characteristic prostrating attacks of headache pain. The Board thus finds that prior to October 10, 2019, the Veteran had headaches, but they were not prostrating or disabling. The Board looks in that connection to the July 2012, January 2016 and March 2017 examinations, in each of which the Veteran was acknowledged to have headache pain and related symptomatology but was not found to experience characteristic prostrating attacks of migraine or non-migraine pain. Accordingly, the Board finds that prior to October 10, 2019, a noncompensable rating is warranted for the Veteran’s headaches. However, the Veteran was afforded a VA examination on October 10, 2019 to assess the nature and severity of his headache disability. The Veteran reported symptoms of pain, nausea, vomiting, sensitivity to light and sound as well as changes in vision. The examiner pertinently indicated that the Veteran did in fact experience characteristic prostrating attacks of headache pain at a frequency of once a month on average. The examiner further acknowledged that the Veteran’s headaches impact his ability to work, citing several disabling headaches per week. However, the examiner stated that the Veteran does not have very prostrating and prolonged attacks of migraines or non-migraine pain productive of severe economic inadaptability. As such, a disability rating of 30 percent for his service-connected headaches is warranted as of October 10, 2019. The Board further finds that the Veteran is not entitled to a higher rating of 50 percent at any point during the appeal period, as the records do not indicate that he has very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. In analyzing the Veteran’s claim, the Board has fully considered the medical evidence and lay assertions of record. It also recognizes the Veteran’s subjective belief the current severity of his headaches warrants a higher evaluation. Generally, the Veteran is competent to report on his current symptoms and their worsening, and such reporting is deemed credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Although the Board observes that the medical evidence fails to show migraine headaches with very frequent and completely prostrating and prolonged attacks productive of severe economic inadaptability, it nevertheless notes prostrating attacks occurring on an average once a month over the last several months since October 2019. Accordingly, the Board finds that the Veteran’s headaches warrant a noncompensable rating prior to October 10, 2019, and a 30 percent rating thereafter, but no higher. 38 C.F.R. §§ 4.7, 4.71a, Diagnostic Code 8100. Service Connection Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d. 1163 (Fed. Cir. 2004). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d. 1331 (Fed. Cir. 2013). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities are presumed to have been incurred in service if they manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In rendering a decision on appeal, the Board must also analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (“although interest may affect the credibility of testimony, it does not affect competency to testify”). 7. Entitlement to service connection for a left foot disability is denied. 8. Entitlement to service connection for a right foot disability is denied. A review of the Veteran’s service treatment records reflects that there are no complaints, treatment or diagnosis of a bilateral foot disability in service. The Board acknowledges the Veteran’s testimony that there are missing records from his first period of active service in the Marines, and that he had been diagnosed with bilateral plantar fasciitis. The Board will thus concede an in-service event in the form of diagnosis of and treatment for plantar fasciitis, satisfying the second Shedden element. Review of post-service treatment records, however, shows no clinical diagnosis of any foot disability at any point during the appeal period. In this regard, the Board notes that the Veteran was afforded VA foot examinations in July 2012 and in January 2016. Both VA examinations reflect, pursuant to physical clinical evaluation and radiographic imaging, that the Veteran does not have a bilateral foot diagnosis. There is no other evidence of post-service treatment to suggest any foot complaint, treatment or diagnosis of any right or left foot disability. Service connection may only be granted for a current disability. When a claimed condition is not shown, there may be no grant of service connection. Congress specifically limited entitlement for service-connected disease or injury to cases where the incident resulted in a disability. In the absence of proof of a present disability there can be no valid claim. 38 U.S.C. § 1131; Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board acknowledges the Veteran’s complaints of bilateral foot pain and use of shoe inserts. Lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example, a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In the present case, while the Veteran as a lay person may be competent to report symptoms of foot pain, he is not competent to diagnose a foot disability. The diagnosis of a foot disability requires greater medical knowledge and testing to determine a diagnosis, which the Veteran has not shown he possesses. Accordingly, the Veteran is not competent to establish diagnosis for his claimed foot disability. The Board is also cognizant of the ruling in Saunders v. Wilkie, which found that pain alone can constitute a disability. 886 F.3d 1356, 1368 (Fed. Cir. 2018). However, in contrast to Saunders, the Veteran has not demonstrated that his bilateral foot pain results in an impairment of earning capacity. The January 2016 VA examination specifically found no functional impairment. As such, Saunders is not applicable to the case currently before the Board. In the absence of proof of a current disability, there is no valid claim of service connection. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement that a current disability be present is satisfied when a claimant has a disability at any time during the pendency of a claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The record does not demonstrate that the Veteran has been diagnosed with a foot disability at any point during the period on appeal. The threshold element of a service connection claim (a current disability) has not been met; therefore, service connection for a bilateral foot disability must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As the preponderance of the evidence is against the claim for service connection for a bilateral foot disability, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 9. Entitlement to service connection for a left ankle disability is denied. 10. Entitlement to service connection for a left hand disability is denied. A review of the Veteran’s service treatment records reflects that he was diagnosed with cellulitis of the left ankle in service in July 2008. There are no complaints, treatment or diagnosis of a left hand disability in service. The Board acknowledges the Veteran’s testimony that there are missing records from his first period of active service in the Marines, and that he rolled his ankle several times in service, and that he suffered a crush injury to his left hand during this period of active duty. Review of post-service treatment records, however, shows no clinical diagnosis of any left ankle or left hand disability. In this regard, the Board notes that the Veteran was afforded VA ankle examinations in July 2012 and in January 2016. Both VA examinations reflect, pursuant to physical clinical evaluation and radiographic imaging, that the Veteran does not have a left ankle disability, and further, that though he has pain, there is no functional loss. Additionally, the Veteran was afforded a VA hand examination in January 2016. Also pursuant to clinical physical evaluation and radiographic imaging, the examiner found no current disability. In fact, the examiner stated that the Veteran’s hand examination was entirely normal, and that the Veteran’s left hand is without functional loss or impairment. There is no other evidence of post-service treatment which suggests left ankle and left hand complaint, treatment or diagnosis. Service connection may only be granted for a current disability. When a claimed condition is not shown, there may be no grant of service connection. Congress specifically limited entitlement for service-connected disease or injury to cases where the incident resulted in a disability. In the absence of proof of a present disability there can be no valid claim. 38 U.S.C. § 1131; Rabideau v. Derwinski, 2 Vet. App. 141 (1992); Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board acknowledges the Veteran’s complaints of hand and ankle pain. Lay evidence can be competent and sufficient to establish a diagnosis when (1) a layperson is competent to identify the medical condition (sometimes the layperson will be competent to identify the condition where the condition is simple, for example, a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In the present case, while the Veteran as a lay person may be competent to report symptoms of pain, he is not competent to diagnose an ankle or hand disability. The diagnosis of such disabilities requires greater medical knowledge and testing to determine a diagnosis, which the Veteran has not shown he possesses. Accordingly, the Veteran is not competent to establish diagnosis for his claimed hand and ankle disabilities. The Board is also cognizant of the ruling in Saunders v. Wilkie, which found that pain alone can constitute a disability. 886 F.3d 1356, 1368 (Fed. Cir. 2018). However, in contrast to Saunders, the Veteran has not demonstrated that his ankle or hand pain results in an impairment of earning capacity. The Veteran has, in fact, reported that his left hand does not open all the way anymore. See August 2019 hearing transcript. However, as previously noted, clinical range of motion findings were normal upon examination in January 2016. Further, the Veteran reported that his left ankle has limited range of motion and pain on weight bearing. However, the Veteran’s ankle examinations show no range of motion impairment and no evidence of pain on weight bearing. The Board finds the clinical findings supported by radiographic imaging to be more probative than the Veteran’s own lay statements, and further finds that there is no competent evidence of functional impairment as a result of the Veteran’s left ankle and hand pain. As such, Saunders is not applicable to the case currently before the Board. In the absence of proof of a current disability, there is no valid claim of service connection. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement that a current disability be present is satisfied when a claimant has a disability at any time during the pendency of a claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). The record does not demonstrate that the Veteran has been diagnosed with left ankle and hand disabilities at any point during the appeal period. The threshold element of a service connection claim (a current disability) has not been met; therefore, service connection for left ankle and hand disabilities must be denied. Brammer v. Derwinski, 3 Vet. App. 223 (1992). As the preponderance of the evidence is against the claim for service connection for left ankle and hand disabilities, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 11. Entitlement to service connection for a low back disability is denied. The Veteran asserts that his currently diagnosed low back disability is related to his active duty service. The Veteran has a current low back disability, diagnosed as a lumbar strain. See January 2016 VA examination. Therefore, the first Shedden element is met. The Veteran stated that he suffered a back injury during service. He reported having bent down while loading equipment on board a ship, and having heard a pop. He further contends he was placed on bedrest for two weeks, and referred to physical therapy. See January 2016 VA examination and August 2019 hearing transcript. The Board has no reason to doubt the Veteran’s credibility in describing this incident. Thus, the second Shedden element is met. The final element remaining to be discussed is that of nexus. After a careful review of all the evidence, lay and medical, the Board finds that the Veteran’s current low back disability was not incurred in service and symptoms of lumbar strain were not chronic in service or manifested within one year of separation. The Veteran was afforded a VA back examination in July 2012, shortly after separation from service in June 2012. The examiner indicated that the Veteran did not have a diagnosis of a low back disability but acknowledged reports of low back pain. The examiner noted that the Veteran had low back pain on the right side while loading weapons and equipment onto a ship. The Veteran reported continued intermittent low back pain with flare ups. All range of motion studies were normal. Functional loss resulting from low back pain was noted as interference with sitting, standing or weight-bearing. Radiographic imaging showed no arthritis and a normal spine. The Veteran was again afforded a VA back examination in January 2016 to assess the nature and etiology of his disability. The Veteran’s diagnosis of lumbar sprain was acknowledged. The examiner reviewed the Veteran’s medical records and noted that the July 2012 VA examination was normal, and that the Veteran’s record was silent for complaint, treatment or diagnosis of a back disability until radiographic imaging in 2015. The Veteran reported having been seen by the pain clinic and that he missed five days of work due to back pain over the previous year. Physical therapy was also noted to be ongoing. Pertinently, the examiner opined that the Veteran’s back disability is less likely than not related to his service. The examiner reasoned that there is no documented medical evidence of ongoing chronic back condition since discharge from service in 2012, including at his initial VA examination of July 2012, which was entirely normal; and that his radicular symptoms were not present until 2015. Furthermore, the examiner noted a new finding in 2015 of disc bulge or annular tear at L5-S1. Indeed, other than the Veteran’s own lay contentions, there is no evidence of continuing symptoms of a back disability since service, and no evidence that a lumbar spine disability manifested to a compensable degree within a year of separation from active duty service. The Board has conceded, based on the Veteran’s lay contentions, that there was an in-service event. However, the Board notes that the medical evidence does not show any back complaints, treatment or diagnosis until 2015, over three years after service. In addition, no medical professional has concluded that the Veteran’s low back disability is related to his in-service back injury. In fact, the Board finds that the most probative evidence of record is the January 2016 VA examination, as it is based on a thorough review of the Veteran’s medical records and lay contentions and is supported by a thorough rationale. While the Veteran asserts that symptoms of back pain in service were early manifestations of his current lumbar spine disability, he is a lay person, and, while competent to relate observable symptoms such as pain, he is not competent to diagnose a medially complex spinal disorder as he is not shown to possess the requisite medical knowledge, training, or experience to do so. Moreover, a mere conclusory generalized lay statement that a service event or illness caused the claimant’s current condition is insufficient to establish medical etiology or nexus. Waters v. Shinseki, 601 F.3d 1274 (2010). Further, the January 2016 VA examiner considered this contention and nonetheless concluded that the Veteran’s current low back disability is not related to service, to include the in-service injury. Having failed to establish a nexus, the claim must be denied. The Board finds that the competent and credible evidence weighs against finding that the Veteran’s low back disability is related to service; therefore, the benefit-of-the-doubt doctrine does not apply, and the appeal is denied. 12. Entitlement to service connection for a left shoulder disability is denied. The Veteran asserts that his currently diagnosed left shoulder disability is related to his active duty service. The Veteran has a current left shoulder disability, diagnosed as a left shoulder strain. See January 2016 VA examination. Therefore, the first Shedden element is met. The Veteran testified his shoulder pain began in service. He reported that wear and tear from carrying heavy equipment, particularly while on deployment, caused his disability. The Veteran further contends his left shoulder motion is limited, and that he cannot raise his arm above his head. See January 2016 VA examination and August 2019 hearing transcript. The Board has no reason to doubt the Veteran’s credibility in describing his in-service strenuous activity. Thus, the second Shedden element is met. The final element remaining to be discussed is that of nexus. After a careful review of all the evidence, lay and medical, the Board finds that the Veteran’s current left shoulder strain was not incurred in service and symptoms were not chronic in service or manifested within one year of separation. The Veteran was afforded a VA shoulder examination in July 2012, shortly after separation from service in June 2012. The examiner indicated that the Veteran did not have a diagnosis of a left shoulder disability but acknowledged reports of left shoulder pain. The examiner noted that the Veteran had left shoulder pain with physical exercise and training in 2009, for which he did not seek medical attention. The Veteran reported continued intermittent left shoulder pain with raising his arm above his head and twisting motion of the left arm. Flare ups were also reported. All range of motion studies were normal. No functional loss was noted. Radiographic imaging showed no arthritis and a normal left shoulder. The Veteran was again afforded a VA shoulder examination in January 2016 to assess the nature and etiology of his disability. The Veteran’s diagnosis of left shoulder sprain was acknowledged. The examiner reviewed the Veteran’s medical records, and noted that the July 2012 VA examination was normal, and that the Veteran’s record was silent for complaint, treatment or diagnosis of a left shoulder disability until December 2015. The examiner further noted that the Veteran recalled no specific shoulder injury, and reported intermittent pain depending on physical movements involving lifting his arm above his head. Pertinently, the examiner opined that the Veteran’s left shoulder disability is less likely than not related to his service. The examiner reasoned that the Veteran’s current left shoulder strain is a new diagnosis, and that there is no documentation of any prior diagnosis of, or ongoing treatment for, a chronic left shoulder disability either in service or on separation. Indeed, other than the Veteran’s own lay contentions, there is no evidence of continuing symptoms of a left shoulder disability since service, and no evidence that a left shoulder disability manifested to a compensable degree within a year of separation from active duty service. The Board has conceded, based on the Veteran’s lay contentions, that there was an in-service event. However, the Board notes that the medical evidence does not show any left shoulder complaints, treatment or diagnosis until 2015, over three years after service. In addition, no medical professional has concluded that the Veteran’s left shoulder disability is related to his in-service activity. In fact, the Board finds that the most probative evidence of record is the January 2016 VA examination, as it is based on a thorough review of the Veteran’s medical records and lay contentions and is supported by a thorough rationale. While the Veteran asserts that symptoms of left shoulder pain in service were early manifestations of his current left shoulder disability, he is a lay person, and, while competent to relate observable symptoms such as pain, he is not competent to diagnose a medially complex musculoskeletal disorder as he is not shown to possess the requisite medical knowledge, training, or experience to do so. Moreover, a mere conclusory generalized lay statement that a service event or illness caused the claimant’s current condition is insufficient to establish medical etiology or nexus. Waters v. Shinseki, 601 F.3d 1274 (2010). Further, the January 2016 VA examiner considered this contention and nonetheless concluded that the Veteran’s current left shoulder disability is not related to service. Having failed to establish a nexus, the claim must be denied. The Board finds that the competent and credible evidence weighs against finding that the Veteran’s left shoulder disability is related to service; therefore, the benefit-of-the-doubt doctrine does not apply, and the appeal is denied. REASONS FOR REMAND 1. Entitlement to a compensable evaluation for abdomen scars is remanded. Although the Board sincerely regrets the additional delay, a remand is required in this case to afford the Veteran every possible consideration and to ensure that there is a complete and accurate record upon which to decide the Veteran’s appeal. With regard to the claim of entitlement to a compensable evaluation for abdominal scars, the Veteran was last afforded a VA examination for his scars in January 2016, nearly four years prior to the date of this decision. Furthermore, the Veteran indicated in his August 2019 hearing before the undersigned that his scars are unstable, tender to the touch, and painful. These symptoms suggest a potential worsening of the Veteran’s scars. The duty to conduct a contemporaneous examination is triggered when the evidence indicates there has been a material change in disability or that the current rating may be incorrect. See Caffrey v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). Thus, as the record indicates a potential worsening of the Veteran’s service-connected scars since the last examination, a new VA examination should be obtained on remand. The matters are REMANDED for the following action: 1. Any outstanding VA or private treatment records pertinent to the Veteran’s scars must be obtained and associated with the claims file. 2. Thereafter, the Veteran must be afforded a VA examination to determine the current severity and manifestation of his service-connected scars. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s post-service medical records, VA examinations of record, and his assertions. An explanation for all opinions expressed must be provided. The examiner must provide accurate and fully descriptive assessments of all scar symptoms. The examiner must discuss any functional effects of the Veteran’s abdomen scars. Caroline B. Fleming Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G.C., Associate Counsel 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.