Citation Nr: 20006922 Decision Date: 01/28/20 Archive Date: 01/28/20 DOCKET NO. 16-35 119 DATE: January 28, 2020 ORDER Service connection for a lumbar spine disorder is denied. Service connection for a bilateral knee disorder is denied. Service connection for a bilateral ankle disorder is denied. Service connection for hypertension is denied. REMANDED Service connection for bilateral hearing loss is remand. Service connection for tinnitus is remanded. Service connection for a left eye cataract, claimed as a left eye disorder, is remanded. Service connection for bilateral foot plantar warts is remanded. Service connection for penile warts is remanded. FINDINGS OF FACT 1. A lumbar spine disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service and arthritis did not manifest within one year of the Veteran’s discharge from service. 2. A bilateral knee disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service and arthritis did not manifest within one year of the Veteran’s discharge from service. 3. A bilateral ankle disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service and arthritis did not manifest within one year of the Veteran’s discharge from service. 4. Hypertension is not shown to be causally or etiologically related to any disease, injury, or incident in service and did not manifest within one year of the Veteran’s discharge from service. CONCLUSIONS OF LAW 1. The criteria for service connection for a lumbar spine disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a bilateral knee disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 3. The criteria for service connection for a bilateral ankle disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1973 to January 1976. This appeal comes before the Board of Veterans’ Appeals (Board) from March 2014 and September 2015 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Board notes that the Veteran requested a hearing in his January 2016 substantive appeal. The Veteran was scheduled for a videoconference hearing at the before a Veteran Law Judge in February 2019. However, in a January 2019 correspondence, the Veteran withdrew his request for a hearing. The Board therefore finds that the Veteran’s request for a hearing has been withdrawn. 38 U.S.C. § 7107(a)(2). In April 2019, the Veteran’s attorney submitted additional argument in support of this appeal. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. That determination requires a finding of a current disability that is related to an injury or disease in service. Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury that was incurred or aggravated in service. 38 C.F.R. § 3.303(d). Generally, to establish service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313(Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Alternatively, service connection may also be established on a presumptive basis for certain chronic disabilities, including arthritis (or degenerative joint disease) and cardiovascular renal disease, when manifested to a compensable degree within the initial post-service year. See 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). Additionally, a disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). 1. Lumbar Spine Disorder The Veteran asserts that his current lumbar spine disorder is the result of an in-service back injury and that he has suffered from continuous pain since service. See April 2019 Appellate Brief. Service treatment records dated in April 1974 and December 1974 reflect the Veteran’s complaints of back pain as well as a diagnosis of lumbalgia in April 1974. A December 1974 lumbar X-ray revealed no significant abnormality. In a January 1976 Report of Medical History, the Veteran denied that had or ever had recurrent back pain and denied that he ever had any illness or injury other than those already noted. The Board notes that this document was signed by the Veteran. A January 1976 discharge examination found the Veteran’s spine to be normal. Post-service treatment records have not shown that the Veteran was diagnosed with arthritis or degenerative joint disease of the lumbar spine within one from his January 1976 separation from active service. Post-service medical treatment records reflect a current diagnosis of lumbar spine degenerative joint disease, see e.g. October 2013 VA examination for the thoracolumbar spine. Thus, the Board finds that presumptive service connection has not been established, and thus, is not warranted for his lumbar spine disorder. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. An October 2013 VA examiner opined that the Veteran’s lumbar spine disorder was less likely than not incurred in or caused by an in-service injury, event, or illness. As the rationale for this opinion, the VA examiner explained that even though the Veteran was treated for lumbar strain in April 1974 and muscle spasm in December 1974, there is no medical record post service to document chronic back pain after his 1976 separation from service. The VA examiner further explained that there was no history of back trauma during active duty, that an X-ray of the lumbar spine in 1974 is negative and that medical literature does not support the claim that back muscle strain or spasm causes herniated disc or degenerative joint disease of the lumbar spine. This opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). No contrary medical opinion is of record. The Board acknowledges the Veteran’s assertions and sincere belief that he has a diagnosis of a lumbar spine disorder that is related to service. In this regard, the Veteran is competent to report the type of symptoms he experienced in and after service, as this is observable through the five senses. See Layno v. Brown, 6 Vet. App. 465 (1994). However, a determination as to the appropriate diagnosis of the musculoskeletal symptoms, and the etiology thereof, is a complex medical determination which goes beyond lay observation of symptoms. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the question of causation involves a medical subject concerning an internal process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing such as X-rays. In the instant case, there is no suggestion that the Veteran has had any medical training. As such, the question of etiology in this case may not be competently addressed by lay evidence and the opinions of the Veteran are nonprobative evidence. In addition, in adjudicating these claims, the Board must assess not only competency of the Veteran’s statements, but also their credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board notes that the Veteran has indicated that the Veteran had experienced lumbar spine symptoms since service. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). In the instant case, the Board finds such statements to lack credibility as they are inconsistent with the other evidence of record and were made under circumstances indicating bias or interest and, therefore, accords no probative weight to such contentions. In this regard, the Veteran indicated that his lower back condition began in October 2012 in an Application for Compensation and Pension (VA Form 21-526) submitted in November 2012. In a November 2011 private treatment note, the Veteran reported a long history of low back pain that he managed conservatively; no specific information regarding onset or the cause of injury as reported. In a July 2013 VA treatment note, the Veteran reported that his low back pain began about a month and a half ago in the middle of his back, that he did not know what occurred to cause his back pain and that he had never had any injuries or accidents to the back. The July 2013 provider noted that the Veteran was not sure of the mechanism of the injury and that the onset was acute. The Board notes that this July 2013 treatment was an initial evaluation for physical therapy and that statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment. See White v. Illinois, 502 U.S. 346, 355-56 (1991); Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (observing that, although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate). Further, the Veteran denied that had or ever had recurrent back pain and denied that he ever had any illness or injury other than those already noted in a January 1976 Report of Medical History. Therefore, the Board finds that any current, contradictory, assertions as to the Veteran’s onset of lumbar spine symptom during service and continuity of symptoms after service advanced in support of this claim for monetary benefits are deemed not credible. Cartwright v. Derwinski, 2 Vet. App. 24, 25 (1991) (a pecuniary interest may affect the credibility of a claimant’s testimony). Therefore, the Veteran’s current statements, made in connection with his pending claim for VA benefits that his current lumbar spine disorder was due to an in-service injury and that he experienced lumbar spine symptoms since service, are inconsistent with the contemporaneous evidence and, therefore, are not credible. Consequently, the Board assigns no probative weight to such statements. In an April 2019 submission, the Veteran’s attorney asserted that service connection was warranted as VA afforded improper weight to the lack of an X-ray confirming the extent of the spinal damage and that “while the extent of the damage is not directly documented, the injury itself is still documented, was incurred in service, and resulted in affected performance even when the Veteran was still in active service.” However, the severity of an injury or the “extent of spinal damage” is not a factor in determining eligibility for service connection. Rather, and as noted above, a current diagnosis is required, regardless of the severity of that disability or the in-service incident. Contrary to the Veteran’s assertion, VA did consider the December 1974 lumbar X-ray which found no significant abnormality. This argument is without merit. The Veteran’s attorney further suggests in the April 2019 submission that service connection for a lumbar spine disorder is warranted as the Veteran was not able to deploy due to his in-service back injury. In support of this argument, a portion of a VA treatment record reflecting the Veteran’s statement that he was not able to deploy during service due to his in-service back injury was submitted. However, service treatment and personnel records reflect do not documents suggesting that the Veteran was unable to deploy due to this back injury. As discussed above, service treatment records do reflect complaints of back pain. There is no record of the Veteran being issued a physical profile for his back which would have prevented deployment. Service personnel records reflect multiple personnel actions for being absent without leave (AWOL), disobeying a lawful order, aggravated assault and being confined by civil authorities. A January 1976 Memorandum indicates that the Veteran’s command recommended his discharge from service due to his negative attitude, unsatisfactory performance of his duty, disregard for authority and regulations and frequent misconduct. The detailed personnel records are devoid of a suggestion that the Veteran was unable to deploy due to his in-service back injury. Moreover, even if such notations suggesting that the Veteran was unable to deploy due to his back injury were located in the service records, service connection would not be warranted as the persuasive medical evidence of record establishes that the Veteran’s current lumbar spine disorder is not related to his service. This argument is without merit. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for a lumbar spine disorder. As such, that doctrine is not applicable in the instant claim and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 2. Bilateral Ankle Disorder The Veteran asserts that he experiences ankle pain which has continued since the time of military service. Further, the Veteran asserts that service connection for is warranted for the left ankle disorder because VA only contemplated primary in-service injuries as the cause of a “potential bilateral ankle condition”; it did not adequately assess the alternate theory that the continued damage to both ankles resulted from the modified gait the Veteran has from in-service injuries.” Summarily, the Veteran presents various theories about the etiology of his bilateral ankle condition. See April 2019 Appellate Brief. Service treatment records reflect that the Veteran sustained a left sprained ankle on the line of duty in October 1974. An October 1974 physical profile record indicates that the condition was temporary, although expected to exceed 90 days. Subsequent to this left ankle injury, there were no other follow-ups, injuries, and/or treatment noted or documented in the service treatment records for the Veteran’s left ankle. With respect to his right ankle, service treatment records did not contain any complaints, treatment or diagnoses for a right ankle disorder. In a January 1976 Report of Medical History, the Veteran denied that had or ever had lameness and arthritis and denied that he ever had any illness or injury other than those already noted. The Board notes that this document was signed by the Veteran. A January 1976 discharge examination found the Veteran’s lower extremities to be normal. With regard to the left ankle, the Veteran was afforded a VA examination in October 2013. The VA examiner diagnosed the Veteran with tenosynovitis of the left ankle. The VA examiner opined that the Veteran’s left ankle disorder was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness reasoning that his ankle sprain in October 1974 is transitory and that there are no clinical notes in the service treatment records that show he had chronic ankle pain during active service. The examiner further reasoned that there are no medical records, post service, to document ankle pain after release from active duty and that his current ankle pain began five years ago. This opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. No contrary medical opinion is of record. With respect to his claimed right ankle disorder, the Board acknowledges that the Veteran has not been afforded a VA examination to determine its nature and etiology. However, the Board finds that such an examination is not required. In this regard, in determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran’s claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran’s service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the United States Court of Appeals for Veterans Claims (Court) has stated that this element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and the veteran’s service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Veteran’s service treatment records do not reflect complaints, treatments or diagnoses related to a right ankle disorder. Further, the evidence does not indicate that his current right ankle disorder may be related to his military service. See McLendon, supra. In this regard, while the Veteran himself has advanced such a theory, a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Court has held that VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Therefore, the Board finds that a VA examination and/or opinion is not necessary to decide the claim for service connection for a right ankle disorder. The Board acknowledges the Veteran’s assertions and sincere belief that he has a diagnosis of a bilateral ankle disorder that is related to service. In this regard, the Veteran is competent to report the type of symptoms he experienced in and after service, as this is observable through the five senses. See Layno, supra. However, a determination as to the appropriate diagnosis of the musculoskeletal symptoms, and the etiology thereof, is a complex medical determination which goes beyond lay observation of symptoms. See Jandreau, supra; see also Woehlaert, supra. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training or experience are competent to provide evidence on the issue. See Jones, supra. In this regard, the question of causation involves a medical subject concerning an internal process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing such as X-rays. In the instant case, there is no suggestion that the Veteran has had any medical training. As such, the question of etiology in this case may not be competently addressed by lay evidence and the opinions of the Veteran are nonprobative evidence. In addition, in adjudicating these claims, the Board must assess not only competency of the Veteran’s statements, but also their credibility. See Buchanan, supra. The Board notes that the Veteran has indicated that the Veteran had experienced lumbar spine symptoms since service. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza, supra. In the instant case, the Board finds such statements to lack credibility as they are inconsistent with the other evidence of record and were made under circumstances indicating bias or interest and, therefore, accords no probative weight to such contentions. In this regard, the Veteran indicated that his bilateral ankle condition began in October 2012 in an Application for Compensation and Pension (VA Form 21-526) submitted in November 2012. In a November 2011 private treatment note, the Veteran reported bilateral ankle pain for one year with a gradual onset. In an October 2013 VA ankle examination report, the Veteran reported the onset of left ankle pain five years ago. In a May 2013 VA treatment note, the Veteran reported complaints of ankle pain for the past three days. In an August 2012 VA treatment note, the Veteran reported ankle pain for the past several years without a history of inciting trauma. The Board notes that the August 2012 VA treatment note was to establish care. The Board notes that statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment. See White, supra; Rucker, supra. Further, the Veteran denied that had or ever had lameness or arthritis and denied that he ever had any illness or injury other than those already noted in a January 1976 Report of Medical History. Therefore, the Board finds that any current, contradictory, assertions as to the Veteran’s onset of ankle symptoms during service, and continuity of symptoms after service, advanced in support of this claim for monetary benefits, are deemed not credible. Cartwright, supra. Furthermore, as the Board finds that the Veteran is not service-connected for a lumbar spine disorder and/or a left ankle, lacks legal grounds to establish entitlement to service connection for a bilateral ankle disorder as secondary a lumbar spine disorder and/or a right ankle disorder as secondary to a left ankle disorder. See Sabonis v. Brown, 6 Vet. App. 426 (1994). As there is no legal entitlement, the claim of entitlement to service connection for a bilateral ankle disorder as secondary to a lumbar spine disorder and service connection for a right ankle disorder secondary to a left ankle disorder is without legal merit. Consequently, the Board must find that a bilateral ankle disorder is not caused or aggravated by a service-connected disability. Therefore, service connection for such disorder is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for a bilateral ankle disorder. As such, that doctrine is not applicable in the instant claim and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 3. A Bilateral Knee Disorder The Veteran asserts that his bilateral knee disorder is a result of his active service. See Generally, April 2019 Appellate Brief. The Veteran further asserts that his knee condition is the result of a modified or antalgic gait caused by his lumbar spine disorder. Service treatment records have no documented evidence of in-service complaints, treatment, and/or a diagnosis for a knee condition. In a January 1976 Report of Medical History, the Veteran denied that had or ever had trick or locked knee and denied that he ever had any illness or injury other than those already noted. The Board notes that this document was signed by the Veteran. A January 1976 discharge examination found the Veteran’s lower extremities to be normal. Post-service treatment records have not shown that the Veteran was diagnosed with arthritis or degenerative joint disease of the lumbar spine within one from his January 1976 separation from active service. Post-service medical treatment records reflect an assessment of bilateral knee pain most likely due to mild knee osteoarthritis versus inflammatory knee arthritis in a November 2011 private treatment record. Thus, the Board finds that presumptive service connection has not been established, and thus, is not warranted for a bilateral knee disorder. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. With respect to his claimed bilateral knee disorder, the Board acknowledges that the Veteran has not been afforded a VA examination to determine its nature and etiology. However, the Board finds that such an examination is not required. In this regard, in determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran’s claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran’s service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court has stated that this element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and the veteran’s service. McLendon, supra. The Veteran’s service treatment records do not reflect complaints, treatments or diagnoses related to a knee disorder. Further, the evidence does not indicate that his current knee disorder may be related to his military service. See McLendon, supra. In this regard, while the Veteran himself has advanced such a theory, a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. See Waters, supra. The Court has held that VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell, supra. Therefore, the Board finds that a VA examination and/or opinion is not necessary to decide the claim for service connection for a bilateral knee disorder. The Board acknowledges the Veteran’s assertions and sincere belief that he has a diagnosis of a bilateral knee disorder that is related to service and/or related to an altered gait caused by his lumbar spine disorder. In this regard, the Veteran is competent to report the type of symptoms he experienced in and after service, as this is observable through the five senses. See Layno, supra. However, a determination as to the appropriate diagnosis of the musculoskeletal symptoms, and the etiology thereof, is a complex medical determination which goes beyond lay observation of symptoms. See Jandreau, supra; see also Woehlaert, supra. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training or experience are competent to provide evidence on the issue. See Jones, supra. In this regard, the question of causation involves a medical subject concerning an internal process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing such as X-rays. In the instant case, there is no suggestion that the Veteran has had any medical training. As such, the question of etiology in this case may not be competently addressed by lay evidence and the opinions of the Veteran are nonprobative evidence. In addition, in adjudicating these claims, the Board must assess not only competency of the Veteran’s statements, but also their credibility. See Buchanan, supra. The Board notes that the Veteran has indicated that the Veteran had experienced lumbar spine symptoms since service. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza, supra. In the instant case, the Board finds such statements to lack credibility as they are inconsistent with the other evidence of record and were made under circumstances indicating bias or interest and, therefore, accords no probative weight to such contentions. In this regard, the Veteran indicated that his bilateral knee condition began in October 2012 in an Application for Compensation and Pension (VA Form 21-526) submitted in November 2012. In a November 2011 private treatment note, the Veteran reported bilateral knee pain, with the right knee worse than the left knee, for one year with a gradual onset. In an August 2012 VA treatment note, the Veteran reported bilateral knee pain for the past several years without a history of inciting trauma. The Board notes that the August 2012 VA treatment note was to establish care. The Board notes that statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment. See White, supra; Rucker, supra. In an October 2013 VA examination report, the Veteran denied that a history of knee trauma. Further, the Veteran denied that had or ever had a trick or locked knee and denied that he ever had any illness or injury other than those already noted in a January 1976 Report of Medical History. Therefore, the Board finds that any current, contradictory, assertions as to the Veteran’s onset of ankle symptoms during service, and continuity of symptoms after service, advanced in support of this claim for monetary benefits, are deemed not credible. Cartwright, supra. The Board notes that arguments of the Veteran’s attorney that the Veteran’s bilateral knee disorder is the result of an altered gait caused by his lumbar spine disorder and/or bilateral ankle disorder. However, the Veteran is not service-connected for a lumbar spine disorder and/or a bilateral ankle disorder, lacks legal grounds to establish entitlement to service connection for a bilateral knee disorder as secondary to such disorder. See Sabonis, supra. As there is no legal entitlement, the claim of entitlement to service connection for a bilateral knee disorder as secondary to a lumbar spine disorder and/or a bilateral ankle disorder is without legal merit. Consequently, the Board must find that a bilateral knee disorder is not caused or aggravated by a service-connected disability. Therefore, service connection for such disorder is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for a bilateral knee disorder. As such, that doctrine is not applicable in the instant claim and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 4. Hypertension The Veteran asserts that the Veteran had “pain or pressure in chest”, even at the time of his entry into service, and that records are unclear about treatment of condition, which suggests that a condition may have existed, “warranting greater duty to treat and evaluate, in order to understand possible aggravation of a pre-existing condition.” See April 2019 Appellate Brief. The Board notes that a Veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service except as to defects, infirmities, or disorders noted at entrance into service or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). An October 1973 service entrance examination found the Veteran’s heart to be normal and noted his blood pressure to be 122/70. In an accompanying October 1973 Report of Medical History, the Veteran had reported infrequent pain in the chest after physical exercise with the examining physician finding a negative symptom assessment. Therefore, the Veteran was found to be sound on service entrance and the presumption of soundness attaches. The presumption of soundness is only rebutted where the evidence clearly and unmistakably shows that the veteran’s disability (1) existed before acceptance and enrollment into service and (2) was not aggravated by service. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); VAOPGCPREC 3-2003 (July 16, 2003). The two parts of this rebuttal standard are referred to as the “preexistence prong” and the “aggravation prong.” Horn v. Shinseki, 25 Vet. App. 231, 234 (2012). The remaining service treatment records are negative for complaints, treatments or diagnoses related to hypertension. Although the Veteran’s attorney asserts that VA did not properly evaluate the potential aggravation of a preexisting condition to service, there is no actual allegation or evidence that the Veteran’s hypertension clearly and unmistakably preexisted his entrance into service. The Veteran reported a diagnosis of hypertension in 1990 in an October 2013 VA examination report. In an October 1973 Report of Medical History, the Veteran denied that he had or ever had high blood pressure and that he ever had any illness or injury other than those already noted. There is no evidence or indication that the Veteran’s hypertension clearly and unmistakably preexisted service other than the recent bald assertions of the Veteran’s attorney. This argument is therefore without merit. Although the medical evidence reflects a current diagnosis of hypertension, medical treatment records have not shown that a diagnosis hypertension was present, and manifested to a compensable degree, within one year of his separation from service, in January 1976. The Veteran had reported that his hypertension was diagnosed in 1990 and a September 2009 private treatment note reflects a clinical indication of hypertension. Thus, the Board finds that presumptive service connection has not been established, and thus, is not warranted for hypertension. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Nonetheless, although presumptive service connection is not established for hypertension, the Board has also considered whether service connection is warranted on a direct basis. In this regard, the Veteran has not provided any medical evidence of an in-service injury, illness or event relating to hypertension. With respect to his claimed hypertension, the Board acknowledges that the Veteran has not been afforded a VA examination to determine its nature and etiology. However, the Board finds that such an examination is not required. In this regard, in determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a Veteran’s claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran’s service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court has stated that this element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and the veteran’s service. McLendon, supra. The Veteran’s service treatment records do not reflect complaints, treatments or diagnoses related to hypertension. Further, the evidence does not indicate that his current knee disorder may be related to his military service. See McLendon, supra. In this regard, while the Veteran himself has advanced such a theory, a mere conclusory generalized lay statement that service event or illness caused the claimant’s current condition is insufficient to require the Secretary to provide an examination. See Waters, supra. The Court has held that VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell, supra. Therefore, the Board finds that a VA examination and/or opinion is not necessary to decide the claim for service connection for hypertension. The Board acknowledges the Veteran’s assertions and sincere belief that he has a diagnosis of hypertension that is related to service. In this regard, the Veteran is competent to report the type of symptoms he experienced in and after service, as this is observable through the five senses. See Layno, supra. However, a determination as to the appropriate diagnosis of the musculoskeletal symptoms, and the etiology thereof, is a complex medical determination which goes beyond lay observation of symptoms. See Jandreau, supra; see also Woehlaert, supra. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training or experience are competent to provide evidence on the issue. See Jones, supra. In this regard, the question of causation involves a medical subject concerning an internal process extending beyond an immediately observable cause-and-effect relationship and requires the administration and interpretation of diagnostic testing such as blood pressure readings. In the instant case, there is no suggestion that the Veteran has had any medical training. As such, the question of etiology in this case may not be competently addressed by lay evidence and the opinions of the Veteran are nonprobative evidence. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for hypertension. As such, that doctrine is not applicable in the instant claim and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. REASONS FOR REMAND The Board regrets further delay, but additional development is necessary before a decision may be rendered on the remaining issues on appeal. 1. Bilateral Hearing Loss and Tinnitus The Veteran asserts that his current bilateral hearing loss and tinnitus are the result of his service, to include an in-service head injury. Service treatment records document that the Veteran fell and hit his head in November 1974, resulting in an abrasion to the orbit of the eye. To date, a VA examination to determine the nature and etiology of the claimed bilateral hearing loss and tinnitus has not been provided. Such should be conducted on remand. 2. Left Eye Disorder The Veteran asserts, in pertinent part, that VA did not adequately contemplate whether the cataracts could be the result of an in-service injury/trauma. See April 2019 Appellate Brief. The Veteran was afforded a VA examination for eye conditions in June 2015. After this examination, a VA examiner opined that the Veteran’s eye condition was less likely than not incurred in or caused by an in-service injury, event or illness. As the rationale for this opinion, the VA examiner reasoned that the “recent decrease in vision is most likely due to the cataract forming.” However, this opinion is inadequate for determining this claim because the VA examiner failed to address evidence of all in-service complaints and/or treatment for the Veteran’s left eye, to determine whether there is any correlation between the in-service complaints and/or treatment for the left eye, and his current left eye cataracts. On remand, an addendum opinion should be obtained that addresses whether the Veteran’s current left eye disorder is the result of his in-service head injury. 3. Left & Right Feet Plantar Warts (Bilateral Plantar Warts) The Veteran was afforded a VA examination for skin conditions in June 2015. After this examination, a VA examiner opined that it was less likely than not the Veteran’s bilateral plantar warts was incurred in or caused by an in-service injury, event, or illness. However, the Board finds that this VA opinion is inadequate for determining this claim because the VA examiner provided an ambiguous, conflicting speculative rationale for her opinion. Specifically, in pertinent part, the VA examiner first acknowledged that the Veteran was treated for plantar warts in-service on one occasion. Additionally, she indicated that it is unclear how the Veteran developed plantar warts within a year of his enlistment into service. However, to the contrary, she determined that it is less likely than not incurred in service (or caused by in-service injury, event, or illness). Further, she stated that “if the pain or discomfort of friction continued past the one time[,] then one could likely speculate an aggravation or chronicity of the condition by service requirements . . . [and it] is therefore less likely than not incurred or caused by any service injury or event. On remand, an addendum opinion should be obtained. 4. Penile Warts The Veteran asserts that service connection for penile warts is warranted because the Veteran manifested penile warts and associated symptoms while in service, which were unsuccessfully treated in 1974 and 1975. See April 2019 Appellate Brief. Pertinently, the Veteran cited the New Zealand HPV Project to assert that “‘rarely, [penile warts can] cause symptoms, such as itching, pain, or bleeding.” The Veteran was afforded a VA examination for the male reproductive system in June 2015. The VA examiner opined that the Veteran’s penile warts as documented and treated in December 1974 and June 1975 were coincidental to his complaints of itching and rash in his groin area and were likely from tinea cruis. The VA examiner further explained that the Veteran’s warts were also during the same periods in which the Veteran was treated for gonorrhea and likely following unprotected sexual activity that was unrelated to his service. The VA examiner explained that HPV is known to manifest about six weeks or so after contact and that it takes the first three months, after treatment, to recur. The VA examiner further stated that “to say . . . that any current penile wart out of the 40+ types of HPV that specifically affect the genital area is caused by the same wart some 40 plus years ago is mere speculation since it is possible he contracted new HPV since he retired from service, and that it is less likely than not this is the penile/genital wart he contracted in service.” On remand, an addendum opinion should be obtained that addresses the Veteran’s contentions and the cited medical literature. On remand, the Veteran should be asked to furnish, or to furnish an authorization to enable VA to obtain, any additional private treatment records from providers who treated him for his claimed disabilities. Finally, given the time that will elapse on remand, updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. The Veteran should be given an opportunity to identify any outstanding private or VA treatment records relevant to the claims on appeal. After obtaining any necessary authorization from the Veteran, all outstanding records, to include updated VA treatment records dated from July 2019 to the present, should be obtained. For private treatment records, make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. For federal records, all reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Schedule the Veteran for a new VA examination to determine the nature and etiology of his claimed bilateral hearing loss and tinnitus with an appropriate VA examiner. The VA examiner must review the claims file and must note that review in the report. A copy of this REMAND must be made available to the VA examiner. The VA examiner must undertake the following: a. The examiner should opine as to whether it is at least as likely as not (50 percent probability or greater) that any diagnosed hearing loss was related to active service, to include a November 1974 head injury. b. The examiner should also opine whether it is at least as likely as not (50 percent probability or greater) that any tinnitus was related to active service, to include a November 1974 head injury. A detailed explanation is requested for all opinions provided. If an opinion cannot be provided without resort to speculation, provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be rendered. 3. Schedule the Veteran for a new VA examination to determine the nature and etiology of his left eye disorder with an appropriate VA examiner. The need for further physical examination is left to the discretion of the examiner. The VA examiner must review the claims file and must note that review in the report. A copy of this REMAND must be made available to the VA examiner. The VA examiner must undertake the following: Opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s left eye disorder, to include left eye cataract, is a result of an illness, injury, or event in service; incurred in service; and/or is otherwise related to his active service. The examiner should specifically address the November 1974 head injury that resulted in an abrasion to the orbit of the eye. In forming a medical opinion, the VA examiner must consider all relevant evidence, including and not limited to evidence of in-service complaints, treatment, and/or diagnoses relating to the Veteran’s left eye. A detailed explanation is requested for all opinions provided. If an opinion cannot be provided without resort to speculation, provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be rendered. 4. Schedule the Veteran for a new VA examination to determine the nature and etiology of his left foot and right foot (bilateral) plantar warts with an appropriate VA examiner. The need for further physical examination is left to the discretion of the examiner. The VA examiner must review the claims file and must note that review in the report. A copy of this REMAND must be made available to the VA examiner. The VA examiner must undertake the following: Opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s bilateral plantar warts were incurred in service; a result of an illness, injury, or event in service; and/or is otherwise related to his active service. In forming a medical opinion, the VA examiner must consider all relevant evidence, including and not limited to service treatment records which document complaints, injuries, and/or treatment for plantar warts and/or related skin disorders in the left and/or right feet. A detailed explanation is requested for all opinions provided. If an opinion cannot be provided without resort to speculation, provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be rendered. 5. Obtain an addendum opinion from the VA examiner that rendered the June 2015 VA opinion on the etiology of the Veteran’s penile warts. If this VA examiner is unavailable, obtain the addendum opinion from another VA examiner. If the June 2015 VA examiner is unavailable, and if it is required and/or pertinent to the adjudication of this claim, schedule the Veteran for a new VA examination on the male reproductive system. The VA examiner must review the claims file and must note that review in the report. A copy of this REMAND must be made available to the VA examiner. The VA examiner must undertake the following: Opine whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s penile warts was incurred in service, related to his service; and/or is otherwise related to his active service. In rendering this opinion, the VA examiner must also consider medical literature, submitted by the Veteran, in support of his claim, including and not limited to, The New Zealand HPV Project. By addressing medical literature, explain any discrepancies with the findings from the pertinent medical literature, with a complete, detailed rationale. A detailed explanation is requested for all opinions provided. If an opinion cannot be provided without resort to speculation, provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be rendered. Kristy L. Zadora Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Vanessa-Nola Pratt, 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.