Citation Nr: 20006243 Decision Date: 01/24/20 Archive Date: 01/24/20 DOCKET NO. 16-08 331 DATE: January 24, 2020 ORDER 1. Entitlement to an increased rating in excess of 10 percent for gastroesophageal reflux disease (GERD) is denied. 2. Entitlement to an increased rating in excess of 10 percent for right knee degenerative joint disease is denied. 3. Entitlement to an increased rating in excess of 10 percent for left knee degenerative joint disease is denied. 4. Entitlement to a compensable rating for tension headaches is denied. 5. New and material evidence to reopen the claim of entitlement to service connection for a right hip disability has been received. 6. New and material evidence to reopen the claim of entitlement to service connection for a left hip disability has not been received. 7. The reopened claim of entitlement to service connection for a right hip disability is denied. FINDINGS OF FACT 1. GERD is not manifested with persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 2. Right knee degenerative joint disease is not manifested with limitation of flexion of the right knee to 30 degrees. 3. Left knee degenerative joint disease is not manifested with limitation of flexion of the left knee to 30 degrees. 4. Tension headaches are not manifested with with characteristic prostrating attacks averaging one in two months over last several months. 5. In an unappealed June 2013 rating decision, the RO denied service connection for a right hip disability based on a finding that the Veteran did not have a current diagnosis of a right hip disability; and denied service connection for a left hip disability based on a finding that the Veteran’s left hip disability was not incurred in or otherwise related to service. 6. Evidence submitted subsequent to the June 2013 rating decision that denied service connection for a right hip disability is not cumulative or redundant of evidence previously of record, relates to unestablished facts necessary to substantiate the claim, and raises a reasonable possibility of substantiating the claims for service connection for a right hip disability. 7. Evidence received subsequent to the June 2013 rating decision denying service connection for a left hip disability is cumulative or redundant of evidence previously of record, does not relate to an unestablished fact necessary to substantiate the claim, and does not raise a reasonable possibility of substantiating the claim. CONCLUSIONS OF LAW 1. The criteria for an initial increased rating in excess of 10 percent for GERD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.114, DC 7399-7346. 2. The criteria for an increased rating in excess of 10 percent for right knee degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, DC 5260-5003. 3. The criteria for an increased rating in excess of 10 percent for left knee degenerative joint disease have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1-4.14, 4.40, 4.45, 4.59, 4.71a, DC 5260-5003. 4. The criteria for a compensable rating for tension headaches have not been met. 38 U.S.C. §§ 1155, 5107(b); 38 C.F.R. §§ 4.1-4.14, 4.124a, DC 8100. 5. The June 2013 rating decision denying service connection for a right hip disability and for a left hip disability is final. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. 6. The criteria for reopening the claim of entitlement to service connection for a right hip disability on the basis of new and material evidence have been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). 7. The criteria for reopening the claim for service connection for a left hip disability on the basis of new and material evidence have not been met. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 2009 to June 2009 and from January 2011 to January 2012. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in July 2019. A transcript of the hearing was prepared and associated with the claims file. Increased Rating Disability evaluations are determined by evaluating the extent to which a Veteran’s service-connected disability adversely affects the Veteran’s ability to function under the ordinary conditions of daily life, including employment, by comparing the Veteran’s symptomatology with the criteria set forth in the Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings represent as far as can practicably be determined the average impairment in earning capacity resulting from such diseases and injuries and the residual conditions in civilian occupations. Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination upon which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervations, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. A little used part of the musculoskeletal system may be expected to show evidence of disuse, either through atrophy, the condition of the skin, absence of normal callosity or the like. 38 C.F.R. § 4.40. Evidence of pain, weakened movement, excess fatigability, or incoordination must be considered in determining the level of associated functional loss, taking into account any part of the musculoskeletal system that becomes painful on use. The provisions regarding the avoidance of pyramiding, see 38 C.F.R. § 4.14, do not forbid consideration of a higher rating based on greater limitation of motion due to pain on use, including flare ups. However, those provisions should only be considered in conjunction with the DCs predicated on limitation of motion. 38 C.F.R. §§ 4.40, 4.45. The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Painful motion is an important factor of joint disability, which is entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. However, the evaluation of painful motion as limited motion only applies when the limitation of motion is noncompensable under the applicable DC. 1. Entitlement to an initial increased rating in excess of 10 percent for GERD In the May 2014 rating decision currently on appeal, the Veteran was granted service connection for GERD and assigned a 10 percent evaluation effective November 4, 2013. The Veteran’s GERD is rated under DC 7399-7346 for hiatal hernias. See 38 C.F.R. § 4.114, DC 7346. A 10 percent disability rating is warranted with two or more of the symptoms for a 30 percent disability rating with less severity. A 30 percent disability rating is warranted for persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A maximum schedular 60 percent disability rating is warranted for symptoms of pain, vomiting, material weight loss, and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. Id. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of an increased rating in excess of 10 percent for GERD. The reasons follow. The evidence shows that the Veteran’s GERD does not result in persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health, to warrant a 30 percent rating. At worst, the Veteran’s GERD is manifested with regurgitation, and pyrosis. For example, the Veteran was found to have dysphagia, reflux, regurgitation, pain, substernal pain, nausea, vomiting, with only occasional episodes of abdominal distress, as stated in the May 2014 VA examinations esophageal conditions and intestinal conditions. At the July 2019 Board hearing, the Veteran testified she suffers from significant discomfort from vomiting and regurgitation. In VA treatment records from September 2019 and October 2019, the Veteran reported incidents of passive regurgitation, heartburn, and abdominal discomfort. The record does not show that the Veteran’s symptoms are productive of considerable impairment of health. For example, in a September 2019 VA treatment record, the Veteran stated her symptoms only manifested occasionally, and that sometimes her symptoms do not manifest for several days at a time. Additionally, while the record shows that the Veteran has several symptoms of GERD, it is not manifested with persistently recurrent epigastric distress. In sum, the evidence does not show that an initial disability rating in excess of 10 percent for GERD is warranted. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran’s claim for an increased rating is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 2. Entitlement to an increased rating in excess of 10 percent for right knee degenerative joint disease 3. Entitlement to an increased rating in excess of 10 percent for left knee degenerative joint disease In a June 2013 rating decision, the Veteran was granted service connection for traumatic injury with patellar tendinitis and findings of degenerative joint disease, right knee and assigned a 10 percent evaluation, effective January 4, 2012. The same decision granted service connection for degenerative joint disease, left knee and assigned a 10 percent evaluation effective April 5, 2013. In the May 2014 rating decision currently on appeal, the RO continued the 10 percent ratings. The Board notes that the May 2014 rating decision states in the cover page that the 0 percent rating for degenerative joint disease, left knee is continued, but in the “Reasons for Decision” section, it is stated that the Veteran’s 10 percent rating is continued. As the Rating Codesheet shows that the Veteran has had a 10 percent rating since the date of service connection, the Veteran suffers no detriment from this mistake. As the evidence and legal analysis are similar, the two issues shall be jointly discussed as a bilateral knee disability. A September 2015 rating decision continued the 10 percent ratings. The Veteran’s bilateral knee disabilities are rated under DC 5260-5003. Under DC 5260, limitation of flexion of the knee to 45 degrees warrants a 10 percent rating. Limitation of flexion of the knee to 30 degrees warrants a 20 percent rating. Limitation of flexion of the knee to 15 degrees warrants a 30 percent rating. See 38 C.F.R. § 4.71a, DC 5260. DC 5003 provides that if degenerative arthritis is established by x-rays, then the disability is rated under the appropriate DC for the specific joint limitation of motion. When the rating of a specific joint is noncompensable under the codes pertaining to limitation of motion, a rating of 10 percent is for application for each major joint affected by limitation of motion. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of an increased rating in excess of 10 percent for a bilateral knee disability. The reasons follow. The evidence shows that the Veteran’s bilateral knee disability is manifested with pain and limitation of motion, but does not result in limitation of flexion of the right or left knee to 30 degrees to warrant a 20 percent rating. At worst, the Veteran’s bilateral knee flexion was limited to 100 degrees, as documented in the April 2015 VA examination report. VA examinations from May 2013 and May 2014 found bilateral knee flexion to 130 degrees. At the May 2013 VA examination, the Veteran reported flare-ups, and the examiner noted that the flare-ups did not result in additional loss of range of motion, but repetitive motion caused functional loss, resulting in interference with sitting, standing, and weight bearing. The examiner found no objective evidence of painful motion. At the May 2014 VA examination, the Veteran denied experiencing flare-ups but complained of painful motion, and the examiner noted that pain did not result in additional loss of range of motion. At the July 2019 Board hearing, the Veteran complained of flare-ups that resulted in pain, but did not contend that this resulted in additional functional loss. The Board has considered the effects of the Veteran’s symptoms, including pain and functional loss, and the Board concludes that the preponderance of the evidence is against a finding of limitation of flexion of the right or left knee to 30 degrees, which is the criteria needed for a 20 percent rating. Examination results throughout the appeal period show that the Veteran had normal muscle strength and joint stability testing results in her knees, and had flexion between 100 and 130 degrees. Taking into account the evidence of record indicating the Veteran’s regular complaints of pain and other findings of functional loss, the Board finds that the evidence does not reflect that such pain and functional limitations resulted in limitation of flexion of the right or left knee to 30 degrees, which would be required for a finding that the Veteran was entitled to a 30 percent disability rating. Thus, a higher rating under the provisions of 38 C.F.R. §§ 4.40, 4.45, and 4.59 criteria is not approximated in the Veteran’s disability picture for this appeal period. In sum, the evidence does not show that disability ratings in excess of 10 percent for bilateral knee disabilities are warranted. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran’s claim for an increased rating is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. 4. Entitlement to a compensable rating for tension headaches In a June 2013 rating decision, the Veteran was granted service connection for tension headaches, and assigned a noncompensable rating effective January 4, 2012. In the May 2014 rating decision currently on appeal, the noncompensable rating was continued. The rating for the tension headaches has been assigned by analogy under DC 8199-8100. A noncompensable rating is assigned for migraine headaches with less frequent attacks. A 10 percent rating is assigned for migraine headaches with characteristic prostrating attacks averaging one in two months over last several months. A 30 percent rating is assigned for migraine headaches with characteristic prostrating attacks occurring on an average once per month over the last several months. A maximum 50 percent rating is assigned for migraine headaches with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a, DC 8100. The rating criteria do not define “prostrating,” nor has the Court. See Fenderson v. West, 12 Vet. App. 119 (1999) (quoting DC 8100 verbatim but does not specifically address the matter of what is a prostrating attack.). According to WEBSTER’S NEW WORLD DICTIONARY OF AMERICAN ENGLISH, THIRD COLLEGE EDITION (1986), p. 1080, “prostration” is defined as “utter physical exhaustion or helplessness.” A very similar definition is found in DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1367 (28th Ed. 1994), in which “prostration” is defined as “extreme exhaustion or powerlessness.” The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of a compensable rating for tension headaches. The reasons follow. The evidence shows that the Veteran’s tension headaches do not result in migraine headaches with characteristic prostrating attacks averaging one in two months over last several months, to warrant a 10 percent rating. At worst, the Veteran’s tension headaches are manifested by headaches with pulsating or throbbing head pain, pain on both sides of the head, and no characteristic prostrating attacks of migraine pain were found, as stated in the May 2014 VA examination. The examiner also noted that the Veteran states that she believes these episodes of headache are related to her sinus infections and they only occur when she has a sinus infection. The May 2013 VA examination also found tension headaches manifested by headaches with pulsating or throbbing head pain, pain on both sides of the head, but no characteristic prostrating attacks of migraine pain were found. In a December 2013 Social Security Administration (SSA) record, the Veteran stated her headaches last a day or two, and occur between eight and 12 times a month. The Veteran stated that the headaches cause nausea, vomiting, neck pain, throat pain or blurred vision, and prevent her from driving, cooking, cleaning or watching television. At the May 2014 VA examination, the Veteran stated that she had not had a headache in months, and only experienced headaches three times per month. This evidence does not support a finding of characteristic prostrating attacks averaging one in two months over last several months VA treatment records show that although the Veteran has reported severe migraines, she has not reported that her migraines result in characteristic prostrating attacks averaging one in two months over the last several months. For example, in a March 2015 VA treatment record, although the Veteran complained of a headache she characterized as “10/10”, she did not report that her headaches resulted in any sort of exhaustion or helplessness, nor has she contended that this was an example of a characteristic prostrating attack. At the July 2019 Board hearing, the Veteran stated that she now experiences headaches three times per week, and that symptoms were sometimes alleviated with hot showers. In sum, the evidence does not show that a compensable disability rating for tension headaches is warranted. As the preponderance of the evidence is against the claim for a higher rating, the benefit of the doubt doctrine is not for application, and the Veteran’s claim for an increased rating is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3. New and Material Evidence If a claim for service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108. New evidence is defined as existing evidence not previously submitted to agency decisionmakers, while material evidence is defined as existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. 38 C.F.R. § 3.156(a). New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. Only evidence presented since the last final denial on any basis (whether by the Board or RO, and whether upon the merits of the case or upon a previous adjudication that no new and material evidence had been presented) will be evaluated in the context of the entire record. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. Moreover, in determining whether this low threshold is met, consideration need not be limited to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but also whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA’s duty to assist or through consideration of an alternative theory of entitlement. For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. Regardless of the AOJ’s actions, given the previous unappealed denial of the claim on appeal, the Board has a legal duty under 38 U.S.C. §§ 5108 and 7105 to address the question of whether new and material evidence has been received to reopen the claims for service connection. This matter goes to the Board’s jurisdiction to reach the underlying claims and adjudicate the claim on a de novo basis. 5. New and material evidence to reopen the claim of entitlement to service connection for a right hip disability At the July 2019 Board hearing, the Veteran stated that she is now diagnosed with a right hip disability. The Veteran contends that she has submitted new and material evidence sufficient to reopen the claim of entitlement to service connection for a right hip disability. The claim for service connection for a right hip disability was initially denied in a June 2013 rating decision based on a finding that the Veteran did not have a diagnosis of a right hip disability. The Veteran was notified of this determination in a June 2013 letter, which included information about the Veteran’s appeal rights. The Veteran did not appeal this decision. The Veteran has not contended that this rating decision is not final as to this issue. Thus, the June 2013 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The pertinent evidence of record at the time of the June 2013 rating decision included the Veteran’s DD Form 214, service treatment records (STRs), VA treatment records, VA examinations, and the Veteran’s contentions. The evidence added to the file since the last final decision are VA examinations, VA treatment records, lay statements, and copies of STRs. The pertinent evidence of record at the time of the June 2013 rating decision included the Veteran’s DD Form 214, STRs, private medical records, and VA treatment records. The Veteran now seeks to reopen her claim of service connection for a right hip disability on the submission of new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Thus, the Board has reviewed the entire record, with particular attention to the additional evidence received since the last final decision in June 2013. After reviewing the record, the Board finds that the additional evidence received is new and material within the meaning of 38 C.F.R. § 3.156. A review of the record shows that in a July 2015 VA examination, the Veteran was found to have been diagnosed with a right hip disability in October 2016. This evidence is new, because it has not been previously submitted. This evidence is also material because it pertains to the bases for the prior denial, that is, that the Veteran did not have a diagnosis of a right hip disability, and raises a reasonable possibility of substantiating the claim. In this regard, for the purpose of establishing whether new and material evidence has been received, the credibility of the evidence is to be presumed. For these reasons, the Board finds that new and material evidence has been received to reopen service connection for a right hip disability. See 38 C.F.R. § 3.156(a). The reopened claim for service connection for a right hip disability is adjudicated below. 6. New and material evidence to reopen the claim of entitlement to service connection for a left hip disability At the July 2019 Board hearing, the Veteran generally contended that she has submitted new and material evidence sufficient to reopen the claim of entitlement to service connection for a left hip disability. The claim for service connection for a left hip disability was initially denied in a June 2013 rating decision based on a finding that the Veteran’s left hip disability was not incurred in otherwise related to service. The Veteran was notified of this determination in a June 2013 letter, which included information about the Veteran’s appeal rights. The Veteran did not appeal this decision. The Veteran has not contended that this rating decision is not final as to this issue. Thus, the June 2013 rating decision is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. The pertinent evidence of record at the time of the June 2013 rating decision included the Veteran’s DD Form 214, STRs, VA treatment records, VA examinations, and the Veteran’s contentions. The evidence added to the file since the last final decision are VA examinations, VA treatment records, lay statements, copies of previously received STRs, and newly received STRs. The Board has reviewed the entire record, with particular attention to the additional evidence received since the last final decision in June 2013. After reviewing the record, the Board finds that the additional evidence received is not new and material within the meaning of 38 C.F.R. § 3.156. VA treatment records received since the June 2013 decision do not support that the Veteran had in-service disease or injury or complaint of a left hip disability. Although the Veteran has submitted clinical records, the evidence does not establish that the Veteran had in-service disease, injury or complaint of a left hip disability, which was a missing element in the initial claim for service connection. The Veteran’s current treatment records do not provide new and material evidence for the claim of service connection for a left hip disability, as they do not contain any new information relating to the substantiation of the claim at hand. The additional clinical evidence does not relate to an unestablished fact necessary to substantiate the claim, which, again is evidence that the Veteran had in-service injury or complaint of a left hip disability. 38 C.F.R. § 3.156. Some of the STRs received are copies of records that were previously reviewed, and the in-service evaluations of left hip muscle strain were discussed in the April 2013 VA examination, upon which the June 2013 rating decision was based. Thus, the Board concludes that this evidence is not new and material under 38 C.F.R. § 3.156(a) and does not constitute relevant service department records under 38 C.F.R. § 3.156(c) since they were already of record previously. The newly STRs received do not contain records relating to the Veteran’s left hip disability. Thus, the Board concludes that this evidence is not new and material under 38 C.F.R. § 3.156(a) and does not constitute relevant service department records under 38 C.F.R. § 3.156(c) since they do not discuss injuries or symptoms related to the Veteran’s left hip during active service. The Board recognizes that in an April 2013 Dental Report of Medical History the Veteran referenced a previous hip injury. However, this record is from a period of reserve duty, not during active service, and merely mentions a previous injury, without any specificity as to whether this injury was incurred in service. In a July 20, 2013 service record, a Statement of Medical Examination and Duty status noted an injury to the Veteran’s right hip. A Medical Eligibility Verification for the Veteran’s right hip injury was completed on the same date. The Board finds that these records do not constitute relevant service records, as they do not reference the Veteran’s left hip, and exclusively reference the Veteran’s right hip. In light of the foregoing, the Board finds that these records do not constitute relevant service department records for the Veteran’s claim of a left hip disability The evidence received since the last final denial is duplicative or cumulative of prior evidence of record. The Board finds that none of the evidence raises a possibility of substantiating the claim. 38 C.F.R. § 3.156(a). For these reasons, the Board finds that the additional evidence received since the June 2013 decision is not new and material within the meaning of 38 C.F.R. § 3.156(a). Consequently, the claim of service connection for a left hip disability is not reopened. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). 7. The reopened claim of entitlement to service connection for a right hip disability At the July 2019 Board hearing, the Veteran stated that her right hip disability was incurred after a May 2011 biking injury, and was exacerbated by a November 2011 motor vehicle accident during active service. The Veteran alternatively contends that her right hip disability is related to a July 2013 incident where she fell during training, and contends that this incident was found to be in the line of duty. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of service connection for a right hip disability. The reasons follow. The Veteran has been diagnosed with a right hip disability, and thus there is evidence of a current disability, and the Veteran meets first element of a service-connection claim. As to an in-service disease or injury, the STRs show that the Veteran was injured in a May 2011 bike riding incident and in a November 2011 motor vehicle accident. Although the Veteran complained of numerous injuries to her knees and back, and mentioned other related symptoms, she did not reference her hips while seeking treatment for the related injuries. The Board finds that if the Veteran had suffered symptoms related to her hips from these accidents, she would have mentioned them in the course of seeking treatment for other her injuries from the accidents. In an August 2011 service record, the Veteran was found to have “tightened […] hip flexors.” In a July 20, 2013 service record, a Statement of Medical Examination and Duty status noted an injury to the Veteran’s right hip, however, the checkboxes stating if the injury was in the line of duty were left blank, and it was noted that this injury was not likely to result in a claim against the government for future medical care. The fact that the examiner stated the injury was not likely to result in a claim against the government for future medical care, tends to establish that the injury was not incurred during the line of duty. A Medical Eligibility Verification for the Veteran’s right hip injury was completed on the same date, however, the checkboxes stating if the injury was in the line of duty were also left blank. These records are from the Veteran’s reserve duty. Although mostly illegible, the records show that the Veteran was treated at a private medical facility. The record does not otherwise support that the Veteran’s July 2013 injury was incurred in active duty, or that the injury was incurred during the line of duty. In light of the August 2011 finding of tightened hip flexors, the evidence supports a finding of complaints or symptoms related to a right hip disability during service, and the in-service disease or injury element is met. As to evidence of a nexus between the current disability and service, the Board finds that the preponderance of the evidence is against such a nexus. For example, the Veteran was first diagnosed with a right hip disability in October 2014, according to a July 2015 VA examination, which is approximately two years following service discharge, (as well as two years after her left hip disability), and tends to establish that a right hip disability did not have its onset in service. The April 2013 VA examination noted that the Veteran did not have a diagnosis of a right hip disability at that time, which also establishes that the Veteran was not diagnosed with a right hip disability within one year of service, and also tends to establish that a right hip disability did not have its onset in service. In a July 2015 VA examination, the examiner opined that that the Veteran’s right hip disability was less likely than not related to or otherwise incurred in service, explaining that the Veteran’s service records did not support a right hip disability, including the July 2013 references to a right hip injury. The examiner stated that the medical record is silent with regard to any right hip symptoms until diagnosis in October 2014. This opinion establishes that a right hip disability is not related to service. Although the Veteran claims that her right hip disability is related her service, she is not medically trained, and is therefore not qualified to competently opine about medical etiology. In certain instances, lay testimony may be competent to establish medical etiology or nexus. However, the diagnosis of a right hip disability requires specialized training for determinations as to diagnosis and causation, and is therefore, not susceptible to lay opinions on etiology. The origin or cause of the Veteran’s right hip disability is not a simple question that can be determined based on mere personal observation by a lay person, the Veteran’s lay assertion is not competent to establish a nexus. Therefore, as the evidence does not support a relationship between a right hip disability and service, the nexus element is not met. As to presumptive service connection for a chronic disease, the Board finds that the Veteran did not incur an event, injury, or disease related to her current a right hip disability in service and that her right hip disability did not manifest during service or within one year of separation from service. Furthermore, the evidence of record does not demonstrate that the Veteran’s symptoms have been continuous since separation from service in January 2012. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). There were no complaints, diagnosis, or treatment for this disorder for approximately two years following service discharge until the Veteran was diagnosed with a right hip disability in October 2014. The absence of post-service complaints, findings, diagnosis, or treatment for approximately two years after service is one factor that tends to weigh against a finding of continuous symptoms since separation from service. The Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence. A prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. In sum, the Board concludes that the preponderance of the evidence of record is against the Veteran’s claim for service connection for a right hip disability. The benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107(b) is not applicable, as there is no approximate balance of evidence. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Husain, 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.