Citation Nr: 20052915 Decision Date: 08/10/20 Archive Date: 08/10/20 DOCKET NO. 14-44 407 DATE: August 10, 2020 ORDER Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with persistent depressive disorder and panic disorder with agoraphobia prior to July 25, 2014 is denied. Entitlement to a disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD) with persistent depressive disorder and panic disorder with agoraphobia from July 25, 2014 is denied. Entitlement to service connection for scrotum pain, to include as secondary to a hernia condition, is denied. Entitlement to service connection for erectile dysfunction is denied. Entitlement to service connection for a bilateral ankle disability is denied. Entitlement to service connection for a left wrist disability is denied. FINDINGS OF FACT 1. For the period prior to July 25, 2014 the Veteran’s PTSD has been manifested by occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks due to such symptoms as subjective complaints of depressed mood, sporadic panic attacks around crowds, anger, irritability, sadness, lack of motivation, difficulty sleeping, nightmares, self-isolation, problems obtaining and keeping close relationships, and family difficulties, suicidal ideation without intent, below average short-term memory and concentration, among others; but the Veteran’s PTSD did not manifest by occupational and social impairment, with deficiencies in most areas, demonstrated by such symptoms as auditory hallucinations, circumstantial, circumlocutory or stereotyped speech, panic attacks more than once a week, impaired judgment and abstract thinking, or impairment of long-term memory. 2. For the period after July 25, 2014, the Veteran’s PTSD has been manifested by occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; due to such symptoms as difficulty in adapting to a worklike setting; difficulty in adapting to stressful circumstances; difficulty in adapting to work; inability to establish and maintain effective relationships; near-continuous depression affecting the ability to function independently, appropriately and effectively; appropriately and effectively, passive suicidal ideation; difficulty in establishing and maintaining effective work and social relationships; disturbances of motivation and mood; flattened affect; impaired judgment; panic attacks more than once a week; anxiety; chronic sleep impairment; depressed mood; and suspiciousness; however, the Veteran’s PTSD was not manifested by total occupational and social impairment, due to such symptoms as: gross impairment in thought process or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, disorientation to time or place, or memory loss for names of close relatives, own occupation or own name. 3. The Veteran does not have a current diagnosis of scrotum pain or functional impairment related thereto. 4. The Veteran does not have a current diagnosis of erectile dysfunction. 5. The Veteran does not have a current diagnosis of a bilateral ankle disability or functional impairment related thereto. 6. The preponderance of the competent and credible evidence shows that the Veteran’s left wrist disability is not related to service. CONCLUSIONS OF LAW 1. The criteria for an initial rating in excess of 30 percent for PTSD with persistent depressive disorder and panic disorder with agoraphobia for the period prior to July 25, 2014 have not been met. 38 U.S.C. §§ 1110, 1131, 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for an initial rating in excess of 70 percent for PTSD with persistent depressive disorder and panic disorder with agoraphobia for the period after July 25, 2014 have not been met. 38 U.S.C. §§ 1110, 1131, 1155, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411. 3. The criteria for service connection for scrotum pain, to include as secondary to a hernia condition, have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304 (2018). 4. The criteria for service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304 (2018 5. The criteria for service connection for a bilateral ankle disability have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304 (2018 6. The criteria for service connection for a left wrist disability have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304 (2018 REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marine Corps from May 1999 to June 1999 and in the United States Army from September 2002 to September 2006, and again from April 2007 to January 2010. These matters come before the Board of Veterans’ Appeals (Board) on appeal from February 2011, May 2011, and September 2011 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a November 2017 Board video conference hearing. A transcript of that hearing has been associated with the claims file. The Board notes that the issue of TDIU was found to have been reasonably raised by the record at the November 2017 Board hearing and was properly before the Board at the time of its May 2018 remand. Rice v. Shinseki, 22 Vet. App. 447 (2009) (citing, Comer v. Peake, 552 F.3d 1362 (Fed. Cir. 2009)). However, in November 2018, the RO granted the Veteran’s claim for TDIU effective June 13, 2014. Therefore, the issue of TDIU is not currently before the Board on appeal. The Board notes that the Veteran’s claim of service connection for a bilateral knee disability was granted by the RO in an April 2020 rating decision. Therefore, this issue is not currently before the Board on appeal. The Board remanded the issues on appeal in a May 2018 decision seeking additional development. Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1 (2013); Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary importance. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). That said, higher evaluations may be assigned for separate periods based on the facts found during the appeal period. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). This practice is known as staged ratings. Id. If the evidence for and against a claim is in equipoise, the claim will be granted. 38 C.F.R. § 4.3. A claim will be denied only if the preponderance of the evidence is against the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When evaluating a mental disorder, the rating agency shall consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126. The rating agency shall assign an evaluation based upon all the evidence of record that bears on occupational and social impairment, rather than solely upon the examiner’s assessment of the level of disability at the moment of the examination. Id. When evaluating the level of disability from a mental disorder, the rating agency will consider the extent of social impairment but shall not assign an evaluation solely on the basis of social impairment. Id. The Veteran’s PTSD is rated under Diagnostic Code 9411. 38 C.F.R. § 4.130. A 30 percent rating is assigned effective January 30, 2010, and a 70 percent rating is assigned effective July 25, 2014. PTSD is rated using the General Rating Formula for Mental Disorders (General Formula). Under the General Formula, a 30 percent disability rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). A 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect, circumstantial, circumlocutory or stereotyped speech, panic attacks more than once a week, difficulty in understanding complex commands, impairment of short- and long-term memory, impaired judgment, impaired abstract thinking, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Id. A 70 percent rating is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); inability to establish and maintain effective relationships. Id. An 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance or minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives and own occupation or name. Id. The “such symptoms as” language means “for example,” and does not represent an exhaustive list of symptoms that must be found before granting the rating of that category. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). The list of examples provides guidance as to the severity of symptoms contemplated for each rating. Id. However, this fact does not make the provided list of symptoms irrelevant. See Vasquez-Claudio v. Shinseki, 713 F.3d 112, 116–17 (Fed. Cir. 2013). The Veteran must still demonstrate either the particular symptoms associated with the rating sought, or other symptoms of similar severity, frequency, and duration. Id. at 117. The nomenclature employed in the rating formula is based upon the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, of the American Psychiatric Association (DSM-5). See 38 C.F.R. § 4.130. In a May 2011 rating decision, the RO service connected the Veteran for posttraumatic stress disorder (PTSD) and major depressive disorder and assigned an evaluation of 10 percent effective January 30, 2010. In a September 2011 rating decision, the Veteran’s disability rating was increased from 10 percent to 30 percent effective January 30, 2010. In an October 2011 Notice of Disagreement, the Veteran stated that he should receive no less than a 70 percent disability rating because his VA examination provided him with a GAF of 40. The Veteran elected to have his NOD reviewed by a Decision Review Office (DRO). In October 2014, the RO issued a Statement of the Case (SOC), which increased the Veteran’s evaluation to 70 percent disabling effective July 25, 2014. The Veteran filed an appeal to the Board on Form 9 in December 2014 seeking a disability rating for PTSD in excess of 30 percent prior to July 25, 2014 and in excess of 70 percent after July 25, 2014. 1. Entitlement to a disability rating in excess of 30 percent for posttraumatic stress disorder (PTSD) with persistent depressive disorder and panic disorder with agoraphobia prior to July 25, 2014. The Veteran’s disability rating was increased to 30 percent in a September 2011 rating decision, based on Portland VA Medical Center (VAMC) treatment records as well as VA and private medical evaluations, dated December 2010. The Veteran was afforded a VA examination in December 2010. During the examination, the Veteran reported having nightmares of the military traumas on a nightly basis where he wakes up with sweats and fright. He reported flashbacks, insomnia, decreased interest in pleasurable activities, decreased concentration, avoidance of trauma triggers such as war news, crowds and traffic. The Veteran reported hypervigilance and increased startle reaction. The Veteran also reported dysphoric mood all the time accompanied by lower energy, poor concentration, decreased interest in pleasurable activities, insomnia, and decreased appetite. The Veteran reported that he has lost weight. The Veteran also reported feelings of hopelessness, helplessness and worthlessness. The Veteran reported suicidal ideation in that he thinks about shooting himself and has his gun stashed under his bed. The Veteran says he gets "stoned" when he has these thoughts and that makes them less intense. The Veteran reported that he has a few close friends, but he does not see them or talk to them. The Veteran has not returned for any additional education or work. He is worried about being around people. He says it is hard enough for him to just go to the grocery store. The Veteran has not been married, has been single for three years, and he is not dating. He stated that he would not be successful in a relationship because it is difficult for him to manage his anxiety level. The Veteran also reported that it is hard for him to socialize with family members; he feels down all the time and has to cover up his feelings. Objectively, the examiner reported that the Veteran is deemed to have normal thought process. He does not report nor appear to have hallucinations or delusions. The Veteran is having difficulty with activities of daily living such as showering or shaving when he gets depressed. The Veteran is oriented to time, place, person, and reason for the evaluation. The Veteran’s short-term memory and concentration is in the below average range. Affect was appropriate to the material discussed but constricted. Mood was dysphoric. The Veteran is reporting suicidal ideation. The Veteran is deemed competent to handle his financial affairs. The examiner reported that the Veteran has not returned for any additional education or work, or been in a relationship. He is concerned about being around people; he said it is hard enough just to go to the grocery store. He has too much anxiety to pursue other areas of function. Since the Veteran’s December 2010 VA examination, he started treatment for PTSD, although he missed quite a few appointments, including a treatment session scheduled for September 14, 2011. The Veteran’s records show that he has some trouble with depression, insomnia, anxiety and sporadic panic attacks. He was going through couples counseling and started school in July 2011. A treatment record dated August 24, 2011 shows that the Veteran quietly talked about withdrawing from school after 4 days. You had enrolled in two classes at the community college. The Veteran stated that he was uncomfortable, almost had a panic attack, and reacted to situations that reminded him of the military with irritability and aggression, and sarcastic humor. He did not like feeling that way or being seen as difficult. The nurse practitioner stated that the Veteran deflected the conversation quietly while admitting that PTSD can affect his future goals. This provider verified that the Veteran stopped taking his psychotropic medication. A VA psychologist reviewed the Veteran’s treatment records and only stated that he was previously diagnosed with an adjustment disorder, but that this had resolved, leaving the Veteran with a diagnosis only of PTSD with major depressive disorder. A December 2010 primary care note indicated that the Veteran was scheduled for anger management classes but did not attend. In December 2010, the Veteran was evaluated by a private psychologist at the Pacific Psychology Clinic. The private treatment record from the Pacific Psychology Clinic noted that the Veteran was referred by VA for evaluation of depression and PTSD. The Veteran reported recent symptoms of paranoia, hypervigilance, suspicion of people close to him, anxiety, depression, anger, irritability, sadness, lack of motivation, difficulty sleeping, nightmares, self-isolation, problems obtaining and keeping close relationships, and family difficulties. Current suicidal ideation was noted. Objectively, the examiner noted that the Veteran arrived on time for his appointment dressed casually, in very well-kept clothes, and nothing was out of place. He was alert and oriented to place, person, time and purpose of the interview. He came prepared with a binder and pen. He was friendly, cooperative, and talkative throughout the interview. He spoke in a tangential manner and in a normal rate and his thought processes were logical but very loosely associated. He endorsed paranoia and suspicion related to the actions and intentions to others and hypervigilance related to being in public areas. In general, his mood was anxious, and affect was blunted to the content of the discussion. The Veteran denied visual or auditory hallucinations. Subjectively, the Veteran reported that he had been unemployed due to his PTSD symptoms sine his discharge from the military. He endorsed feelings of depressed mood and loss of interest in doing activities that he would normally enjoy. The Veteran reported that his energy and appetite are poor ("I don't enjoy food like I used to"). He reported symptoms of guilt, difficulty concentrating, and difficulty sleeping. He indicated that at times he has thoughts of wishing he were dead, though denied any current intent to attempt suicide. The Veteran reported that he has recently experienced symptoms of paranoia, hypervigilance, suspicion of others close to him, anxiety, depression, anger, irritability, sadness, lack of motivation, problems sleeping including reoccurring nightmares and fitful sleep-patterns, and problems falling asleep, antisocial problems such as a desire to isolate self, relationship problems such as problems obtaining and keeping close relationships, and family problems such as fights with his brother and relationship issues with his mother. He stated that these symptoms became noticeable in 2004 and have increased considerably since his discharge from the Army in March 2010, and they are affecting his relationships and family. The examiner also noted that the Veteran expressed suicidal ideation. The Veteran reported that he never attempted suicide, nor does he believe that he will attempt suicide. The Veteran stated that he does currently have a plan but does not have intent to harm himself. He reported that if he were to attempt suicide, he would shoot himself in the head. The Veteran reported that he sleeps with a loaded 9mm in his bed. The Veteran explained that he knew how to be safe with his gun. He reported that he never leaves a round in the chamber and that eventually he would like to feel more comfortable not sleeping with his gun. He reiterated that he does not have intent to commit suicide. He mentioned his nieces and his sister as reasons to avoid self or other harm at this time. He demonstrated moderate to high- risk for self-harm currently due to current suicidal ideation and access to and knowledge of firearms. However, the examiner noted that this risk is somewhat reduced due to the Veteran’s repeated expression of not wanting to harm himself because he would not want to negatively affect his sister’s or his nieces’ lives. An April 2011 mental health consult noted that the Veteran reported intrusive memories, flashbacks, vivid dreams, panic attacks, difficult sleeping, easily startled, anger, irritability, and avoidance. The Veteran denied suicidal ideation. A higher evaluation of 50 percent is not warranted unless there is reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Having reviewed the Veteran’s claims file, the Board finds that the Veteran’s PTSD symptoms more closely approximate a 30 percent disability rating for the period from January 30, 2010 to July 25, 2014 based on evidence of mild memory loss, sporadic panic attacks, anxiety, suspiciousness and normal thought processes, including normal abstract thinking. Although the Veteran reported that he has thought about suicide, he repeatedly indicated that he does not have an intent nor does he think he will commit suicide. In fact, the Veteran denied suicidal ideation according to an April 2011 mental health consult note. As reported by the private psychological evaluation in December 2010, the Veteran’s risk of committing suicide is somewhat reduced due to the Veteran’s repeated expression of not wanting to harm himself because he would not want to negatively affect his sister’s or his nieces’ lives. There is also no indication that the Veteran experiences panic attacks more than once a week, has impaired judgement or impaired abstract thinking, difficulty understanding complex commands, or impairment of short- or long-term memory. Although the Veteran reported that he has not worked or attended school since his discharge from the military due to his PTSD symptoms, is not currently in a relationship and has a strained familiar relationship, the evidence suggests that he has a few close friends, and does have a relationship with his sister and his nieces. Moreover, his inability to return to work or school is based on his fear of crowds rather than the symptoms enumerated under the 50 percent disability rating. Accordingly, the medical and lay evidence overall does not support an initial rating in in excess of 30 percent for PTSD. 2. Entitlement to a disability rating in excess of 70 percent for posttraumatic stress disorder (PTSD) with persistent depressive disorder and panic disorder with agoraphobia from July 25, 2014. On VA exam dated July 2014, the Veteran was diagnosed with panic disorder with agoraphobia. This is in addition to the already diagnosed PTSD and major depression. Based on the results of this VA examination, the Veteran’s disability rating was increased to 70 percent. The effective date assigned for the increase is July 25, 2014, which is the date of the VA examination, which shows that the Veteran met the higher evaluation criteria and the date that another diagnosis was added to the Veteran’s condition. The evaluation of PTSD with persistent depressive disorder and panic disorder with agoraphobia was increased to 70 percent disabling based on the following symptoms: occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood; difficulty in adapting to a worklike setting; difficulty in adapting to stressful circumstances; difficulty in adapting to work; inability to establish and maintain effective relationships; near-continuous depression affecting the ability to function independently, appropriately and effectively; near-continuous panic attacks affecting the ability to function independently, appropriately and effectively, suicidal ideation; difficulty in establishing and maintaining effective work and social relationships; disturbances of motivation and mood; flattened affect; impaired judgment; panic attacks more than once a week; anxiety; chronic sleep impairment; depressed mood; and suspiciousness. The Veteran was afforded another VA examination in May 2019. The examiner noted that the Veteran’s “symptoms have not had any period of remission since the last examination [in July 2014] and, if anything, his degree of isolation, frequency and intensity of panic attacks and depression have worsened since the last examination. The Veteran described daily panic attacks secondary to his PTSD. He continues to rarely leave his house due to panic. He only shops for groceries in the middle of the night when he is least likely to encounter other people or crowds. His symptoms of panic (difficulty breathing, sharp increase in heart rate, sweating, light headedness and feeling like he is going to die) are unchanged from the previous examination and they have generally become more intense and somewhat more frequent. The Veteran described more serious and intense feelings of depression than those described in the last examination. He has daily suicidal ideation but denies intent. He has a plan to hike far into the wilderness and hang himself where he will not be found but has not taken any steps to implement that plan. He cites his son as a protective factor and he recognizes that his suicide would have a devastating effect on his son. He has a handgun but insists he would never use it to hurt himself. The examiner opined that the Veteran exhibits occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood, which is associated with a 70 percent disability rating. The examiner noted that the Veteran’s PTSD, depression and panic disorder continue to cause equal social and occupational impairment. He has been unable to attend college because of panic and depression. His PTSD symptoms make it impossible to tolerate crowds or close contacts with others, and he remains isolated from others due to his mental health conditions. The examiner noted that the Veteran exhibits the following symptoms: Depressed mood, anxiety, suspiciousness, panic attacks more than once a week, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions or recent events; flattened affect; impaired judgment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a worklike setting; inability to establish and maintain effective relationships; and suicidal ideation. The Veteran’s son is his only significant relationship as he has no friends or close family members. His PTSD and fear of getting close to others only to lose them later has led the Veteran to lead a very solitary lifestyle with no significant relationships since his discharge from the military. He is hypervigilant. He has a gun at home for protection but insists he would never use it to hurt himself. He has frequent passive suicidal ideation with a plan to get a rope, hike into a remote region and hang himself. He denies intent, citing his son as a protective factor and he has not taken actions to prepare for such an action. According to a January 2020 mental health outpatient note, the Veteran arrived on time, was well groomed, clean, and attired appropriately for weather. His attitude was cordial, he had no abnormal movements, and had good eye contact. He was alert and the quantity, rate, volume, and rhythm of his speech were within normal range. His thought process was linear and logical. His cognition/orientation was intact, oriented to space, time, self, circumstances. The Veteran had passive suicidal ideation with allusion to plan, but no intention. Following a review of the evidence in the record, the Board finds that the Veteran’s symptoms since July 25, 2014 more closely approximate a 70 percent disability rating. A disability rating in excess of 70 percent is not appropriate because there is no evidence that the Veteran exhibited gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; disorientation to time or place; memory loss for names of close relatives, own occupation, or own name; or intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene). Although the Veteran reported passive suicidal ideation with a plan, the Veteran consistently denied having an intent to harm himself or others. Although the Board notes that the Veteran’s disability has worsened since the July 2014 VA examination, the severity of the Veteran’s disability does not amount to a 100 percent disability rating. In fact, the most recent VA examination, dated May 2019, indicated that the Veteran’s PTSD reflected occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgement thinking or mood rather than total social and occupational impairment. There is no medical or lay evidence provided since the May 2019 VA examination to warrant a higher disability rating. Accordingly, the medical and lay evidence overall does not support an initial rating in in excess of 70 percent for PTSD. Service Connection Service connection will be granted for disability resulting from disease or injury incurred or aggravated by military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). To prevail on a direct service connection claim, there must be competent evidence establishing three elements: (1) the existence of a present disability; (2) in-service incurrence or aggravation of disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 Caselaw Caution (Fed. Cir. 2004); Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Service connection may also be granted on a secondary basis for a disability that is proximately due to or the result of an established service-connected disorder. See 38 C.F.R. § 3.310 (a) (2017); Allen v. Brown, 7 Vet. App. 439 Caselaw Caution (1995). 3. Entitlement to service connection for scrotum pain, to include as secondary to a hernia condition. The Board has reviewed the Veteran's record and finds no current diagnosis of a scrotum condition. During the November 2017 hearing, the Veteran reported that “there’s some atrophy in there, and one scrotum is different from the other one.” He said this impacted his ability to have intimate relations, because it made the experience excruciating and painful for him. He said the pain is constant, and thinks it’s because of the mesh from the hernia surgery. The Veteran’s representative said that the Veteran has a huge scar in the scrotum area as a result of his hernia operation. The Veteran’s STRs reflect that he had complained of groin pain in September 2002, which was later determined to be a left reducible inguinal hernia. The medical note reports that shortly after the Veteran arrived at Fort Jackson, he felt a pull in his left groin and has had pain since then. On examination, he was found to have a reducible mass in the left inguinal area. He underwent surgery in October 2002. In 2005, the Veteran complained of pain in the left groin/LLQ area pain two times per week. No hernia was detected on examination. Service treatment records dated October 2005 reflect that the Veteran’s scrotum was normal but that he reported left side groin pain. No hernia was detected. Service treatment records, dated May 2008, note epididymitis as one of the Veteran’s medical problems. It was noted that the Veteran’s reported inguinal pain “may be due to adhesion/scar tissue which commonly develops after abdominal/pelvic surgery.” The Veteran had a scrotal ultrasound in November 2010. The medical note reported that the Veteran’s testicles are normal upon examination. The provider stated a belief that the Veteran’s “discomfort is coming from post hernia scarring entrapping the nerves that supply the testicle rather than due to an intrinsic testicular problem.” A December 2010 VA treatment record notes that the Veteran complained of residual pain in the left groin with ejaculation, but an ultrasound of the Veteran’s scrotum in 2010 was normal and VA records show multiple somatic complaints at every recent visit. The Veteran complained that he was “worried he has had hernias since August 2003.” An examination at that time revealed no hernias. The Veteran also reported a constant dull ache in his left scrotum when sitting. The Veteran further reported that his penis was somewhat sensitive to touch. The examiner stated a belief that the Veteran’s symptoms stem from his 2002 hernia repair. The Veteran was afforded a VA examination in December 2010. The Veteran reported that in 2002, he underwent a hernia repair uneventfully and recovered without any complications and he returned to basic training after four weeks. The Veteran stated that he now experiences some pain in the left groin area which occurs with activity such as ejaculation but a recent ultrasound as workup for the pain was normal and he is not on any pain medications for it. He reported that he has not had any difficulty in his ability to perform his duties while in the service or after due to this pain which seems to be mild overall. The December 2010 VA examiner diagnosed the Veteran with pain in the left groin and scrotal area. The examiner opined that the “Veteran’s pain was not due to the left inguinal hernia repair he underwent while in the service in 2002. The Veteran made a good recovery from this surgery and was able to perform all his duties during his time in the service until he left the service in March of 2010. A scrotal ultrasound done in November 2010 is an unremarkable scrotal ultrasound. The examiner opined that the pain the Veteran is reporting is not disabling or incapacitating or prostrating and does not interfere with his functional abilities in any way. It cannot be linked to his left inguinal hernia repair done in 2002.” The Veteran was afforded a VA examination in July 2014 for a hernia. The examination was negative for a hernia on the right and left sides. In December 2014, the Veteran was treated for prostatitis. The Veteran complained that he feels like the left testicle is always painful, but a January 2013 urologist at the Portland VA found everything to be normal. The Veteran noted that he has right sided inguinal pain with exercise. The left scar has not caused any problems and is not itself painful in any way. At the time, the Veteran was not on no weightlifting restrictions, nor was he on any pain medications. The Veteran’s most recent VA examination was in May 2019. The Veteran was asked to verbally acknowledge any discomfort incurred during manual and visual examination of the genitalia (to include the penis, testicles and scrotum). No such acknowledgement was forthcoming. No scrotal, penile or testicular pain was reported by the Veteran, nor elicited/objectively observed during examination. The examiner noted that “no scrotal pain was present at exam, and no current ‘scrotal pain disability’ was identified.” The Board notes that the Veteran was service connected for a scar from his left hernioraphy. As noted earlier, the Veteran’s medical service providers have provided inconsistent opinions as to whether the Veteran’s scrotum pain was caused by his hernia surgery or the scar resulting from the surgery. Regardless of whether the residuals of the Veteran’s hernia surgery caused his scrotum pain, and whether the Veteran has symptoms of scrotum pain, there is no current diagnosis of a disability to warrant a grant of service connection. While the Veteran is competent to describe symptoms, the Veteran is not competent to provide a diagnosis of a condition due to the alleged etiology. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board has also carefully considered Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Saunders held that undiagnosed pain can be so debilitating that it can result in functional impairment. See Saunders, 886 F.3d at 1356 (where the evidence shows that symptoms reach the level of a functional impairment of earning capacity, a disability for VA compensation purposes exists, even if there is no underlying diagnosis). Here, the Veteran’s records reflect subjective complaints of pain. However, there is no persuasive evidence showing that the pain results in any functional impairment. Id. (holding that a “disability” under 38 U.S.C. § 1110 refers to functional impairment of earning capacity). As stated previously, in the December 2010 and December 2014 VA examination reports, the examiner performed various diagnostic tests of the Veteran’s scrotum and concluded that the Veteran did not exhibit any functional loss or impairment as a result of the pain. Moreover, the Veteran denied having scrotum pain or taking medications for the pain during the most recent May 2019 VA examination. Accordingly, the examination reflects there is no functional impairment constituting a disability in this case. The preponderance of the evidence is against the claim, and the claim must be denied. 38 U.S.C. § 5107 (b). With no diagnosis, there is nothing for the examiner to draw connection from. A necessary element for establishing entitlement to service connection is the existence of a current disability; it is the cornerstone of a claim for VA disability compensation. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). For VA purposes, a current disability exists when a claimant has a disability at the time a claim is filed or at some point during the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). As there is not evidence of a diagnosis or functional impairment due to pain, the issue of secondary service connection based on the Veteran’s hernia scar does not need to be addressed. Thus, service connection for a scrotum pain condition is not warranted. As a preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection for scrotum pain is denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for erectile dysfunction During the November 2017 hearing, the Veteran testified that he started having erectile dysfunction following his hernia surgery. Service treatment records, dated May 2008, note epididymitis as one of the Veteran’s medical problems. It was noted that the Veteran’s reported inguinal pain “may be due to adhesion/scar tissue which commonly develops after abdominal/pelvic surgery.” The Veteran had a scrotal ultrasound in November 2010. The medical note reported that the Veteran’s testicles are normal upon examination. The provider stated a belief that the Veteran’s “discomfort is coming from post hernia scarring entrapping the nerves that supply the testicle rather than due to an intrinsic testicular problem.” The Veteran’s December 2010 VA examination noted that there was no erectile dysfunction. A VAMC primary care note dated August 2011 reported that the Veteran “cannot have [an] orgasm because of pain/duration of erection and because performance issues in his mind related to pain; has low libido.” A VAMC compensation examination, dated July 2014, notes “some complaint of residual pain in the left groin with ejaculation. A 2011 VAMC primary care exam documents reported “abdomen: NABS, soft and NT. No HSM or masses/guarding or rebound. Left inguinal region with well-healed incision ... bilateral testes without masses or tenderness. Penis without abnormality.” No scrotal pain was present on the day of the exam, and no current “scrotal pain disability” was identified. A 2013 VAMC primary care exam documented “right and left testicles and epididymis are unremarkable and nontender; patient states one week ago his right testicle was extremely tender to very minimal touch...Penis is unremarkable.” The Veteran was afforded a VA examination in July 2014. The examiner opined that the Veteran did not have an erectile dysfunction. The physical examination reflected a normal penis, testes, and epididymis. The Veteran was afforded a VA examination for male reproductive system conditions in May 2019. On examination, the Veteran stated that he gets left side groin pain during intercourse, and rectal pain following ejaculation. The Veteran stated that the left sided groin pain started in 2002 and that his self-described erectile dysfunction had its onset in 2010. There was no causal relationship between left sided groin pain and the self-described erectile dysfunction given that the groin pain preceded the claimed erectile dysfunction by eight years. The Veteran also stated on examination that he developed a very low libido in 2010. The examiner did not diagnose the Veteran with erectile dysfunction. The examination noted that the Veteran’s penis, testes, and epididymis were normal. The examiner noted that the Veteran’s prostate was not examined because the exam was not relevant to the Veteran’s claimed condition. The examiner further added that the Veteran’s claimed male reproductive system conditions did not have an impact on his ability to work. During the examination, the Veteran reported rectal pain during ejaculation, that he was able to get and maintain an erection in the past 12 months, but that less than half of his erections in the past year were suitable for intercourse with ejaculation. The Veteran denied receiving medication for his claimed condition. The examiner opined that the Veteran’s sexual dysfunction is not erectile dysfunction but more likely psychosexual dysfunction. The examiner also opined that it is less likely as not that the Veteran has a diagnosis of erectile dysfunction incurred in or caused by service. The examiner’s medical opinion was based on the May Clinic’s definition of erectile dysfunction (also known as impotence, or the inability to get and keep an erection firm enough for sex) and the Veteran’s lay statements that he had erections suitable for sex. The examiner also opined that it is less likely as not that the Veteran has an erectile dysfunction disability related to an in-service injury, event, or disease, including an in-service hernia repair in 2002. The examiner based his medical opinion on the fact that the Veteran stated he had erections suitable for sexual intercourse. The examiner noted that “no objective medical assessment of ‘functional loss due to pain on use’ is practicable.” The Veteran noted that the pain claimed by the Veteran is not supported by adequate pathology or evidenced by his visible behavior because the Veteran did not verbally acknowledge any discomfort or pain during manual and visual examination of the genitalia (to include the penis, testicles and scrotum), and no scrotal, penile or testicular pain was objectively observed during examination. A necessary element for establishing entitlement to service connection is the existence of a current disability; it is the cornerstone of a claim for VA disability compensation. Brammer, 3 Vet. App. at 225. For VA purposes, a current disability exists when a claimant has a disability at the time a claim is filed or at some point during the pendency of that claim. McClain v., 21 Vet. App. at 321. While the Veteran is competent to describe symptoms, the Veteran is not competent to provide a diagnosis of a condition due to the alleged etiology. See Jandreau, 492 F.3d at 372. The Veteran’s medical treatment records, including the July 2014 and May 2019 VA examinations, did not diagnose the Veteran with erectile dysfunction. Although the Veteran indicated that he felt pain in the rectum during ejaculation and that less than half of his erections in the last year were suitable for intercourse, the Veteran noted that he was able to have and maintain erections suitable for sexual intercourse and anatomically, the Veteran’s reproductive organs were normal on examination. Therefore, the Veteran’s symptoms were not consistent with the Mayo Clinic’s definition of erectile dysjunction. Thus, service connection for erectile dysfunction is not warranted. As a preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply, and the claim for service connection for erectile dysfunction is denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to service connection for a bilateral ankle disability The Veteran contends that he has a bilateral ankle disability as a result of an injury sustained during military service. The Board finds there is insufficient evidence to show that the Veteran has a current bilateral ankle disability as a threshold matter for awarding service connection. During the November 2017 VA examination, the Veteran testified that he injured his ankles during ruck marches on uneven terrain in basic training. He said that because the terrain was uneven and they did the road marches in the morning and late evening, he rolled on his ankles on several occasions. The Veteran’s STRs, including his separation examinations in 2006 and 2009, do not note complaints or treatment for a bilateral ankle condition or abnormalities. The Veteran also reported that he was not seen for his ankles in service in 2002 or 2006. He stated that when he was on active duty in 2007 and 2010, both of his ankles were sore and stiff during ruck marches. The Veteran was afforded VA examinations in December 2010 and May 2019. During the December 2010 VA examination, the Veteran described having intermittent pain that is activity related. His ankles tend to bother him with running and walking and being on uneven surfaces where he would have twisting episodes of his ankles. He said that he experiences flare-ups 1-2 times a week and it takes anywhere from one hour (for a minor flare-up) to seven days (for a twisting injury flare up) for his pain to resolve. He stated that he has had an average of two twisting injuries a year, but now, it is lessening since he is not in active service. The Veteran stated that he avoided going to sick call while in service because he was a Medic and did not want his unit to view him as weak or unable to take care of them. He denied using any assistive devices. On examination, the examiner noted normal bilateral ankles with normal objective findings. The examiner noted no tenderness if the ankle joints bilaterally. Ankle range of motion was 10 degrees of dorsiflexion, 65 degrees of plantar flexion, 40 degrees inversion, and 35 degrees eversion bilaterally. The Veteran described increased pain on repetitive range of motion testing on the right ankle, but none on the left ankle. There was no change in range of motion on repetitive testing. Given his objective findings, the examiner opined that he was unable to link the subjective complaints to a particular injury during active service. During the May 2019 VA examination, the Veteran reported that he has generalized aches with extensive walking and standing for long periods of time that he can get somewhat sore and stiff, but when he rests it goes away. He reported that he is not limited in homework or activities of the ADLs, does not use assistive devices and takes no medication other than occasional Tylenol for generalized body ache. In terms of functional loss or functional impairment, the Veteran noted that his ankles can get sore or stiff at different times of the year depending on his activity level. Range of motion for both ankles was normal with dorsiflexion at 0 to 20 degrees and plantar flexion at 0 to 45 degrees. No pain was noted on examination, including with weight bearing. There was no objective evidence of localized tenders or pain on palpation of the joint or associated soft tissue. There was no additional loss of function or range of motion after three repetitions. The examination was negative for crepitus and muscle strength testing was normal. The examiner reported that ankle instability or dislocation was suspected in both ankles but anterior drawer and talar tilt tests were normal. The Veteran denied using assistive devices. The examiner stated that the Veteran’s claimed condition does not impact his ability to perform any type of occupational task. Finally, the examiner noted that on objective examination, the Veteran has normal ankles on the right and left side, and there is no evidence of pain with weightbearing and non-weight bearing or passive motion bilaterally. Therefore, the examiner opined that it is not at least as likely as not that the Veteran’s claims ankle condition was related to service. The examiner’s opinion was based on the fact that the Veteran’s examination was normal and therefore, there was no evidence that he has an ankle diagnosis or that he has ever had any abnormal ankle diagnosis while on active duty. During both examinations, the Veteran was found to have no diagnosed condition or functional loss that is as likely as not incurred in or related to his active service, including a diagnosed ankle condition during active service. At both examinations, range of motion testing was normal, and no pain was associated with any range of motion or weight bearing on examination. Additional testing, including muscle strength, were all normal. Based on the evidence of record, the Board finds that the Veteran has no current diagnosis of a disability for VA purposes. References to stiffness and soreness in the bilateral ankles are only as reported by the Veteran. No independent diagnosis was indicated, and, in fact, the opposite is true. The VA examiner found no current diagnosis. Consideration has been given to the Veteran's complaints of bilateral ankle pain. However, "pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted." Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) aff'd 259 F.3d 1356 (Fed. Cir. 2001) (affirming on other grounds without addressing pain alone). As ankle pain is not a disability, it cannot by itself be service connected. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("In the absence of proof of a present disability there can be no valid claim."); see also Begmetich v. Brown, 104 F.3d 1328, 1332 (Fed. Cir. 1997). The Board acknowledges, however, that undiagnosed pain can be so debilitating that it can result in functional impairment. See Saunders, 886 F.3d at 1356 (2018) (where the evidence shows that symptoms reach the level of a functional impairment of earning capacity, a disability for VA compensation purposes exists, even if there is no underlying diagnosis). Here, the Veteran's records reflect subjective complaints of pain in the form of stiffness and soreness. However, there is no persuasive evidence showing that the pain results in any functional impairment. Id. at 1363 (holding that a "disability" under 38 U.S.C. § 1110 refers to functional impairment of earning capacity). As stated previously, during the December 2010 and May 2019 VA examination reports, the examiner performed various diagnostic tests of the Veteran's ankles and concluded that the Veteran did not exhibit any functional loss or impairment in bilateral ankles. The Board acknowledges that the requirement of a current disability is satisfied when the Veteran has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim and that the claimant may be granted service connection even though the disability resolves prior to the Secretary's adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). However, the evidence does not reflect that the Veteran had chronic pain that resolved during the pendency of the claim. Rather, as discussed, the Board finds that the most probative evidence (i.e. the December 2010 and May 2019 VA examination reports) indicates that the Veteran did not have a bilateral ankle disability at any point during the appeal period or prior to his filing a claim for service connection. See Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). Further, there are no records since the Veteran's separation that indicate that he has or had arthritis or any other bilateral ankle disability. In summary, the Veteran has not demonstrated that his subjective complaints of pain reach the level of functional impairment of earning capacity, and there is no medical evidence that the Veteran exhibits a bilateral ankle disability. As a lay person, the Veteran is competent to relate some symptoms such as pain, but he generally does not have the requisite medical knowledge, training, or experience to be able to diagnose an underlying disorder. Kahana v. Shinseki, 24 Vet. App. 428, 437 (2011). In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. Given that no ultimate, material issues are in equipoise, that doctrine is not applicable in the instant appeal. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. Accordingly, the Board finds that the preponderance of evidence is against a finding that there is a right ankle disability for which service connection could be granted. Therefore, the claim for service connection for a bilateral ankle disability must be denied. 38 U.S.C. § 5107; Gilbert, 1 Vet. App. at 49. 6. Entitlement to service connection for a left wrist disability The Veteran reported that he injured his left wrist when he was lifting and carrying rucksacks, as well as generally lifting constantly with his left hand while in service. He believes that he injured his left wrist in boot camp and during his first period of active duty from 2002 to 2006. He reported that when he got out of the service, he had a generalized ache in the lateral aspect of the wrist. He stated that when he returned to the service, he did not mention and they could not recall, if it was anything more than some mild ache. He was in the service on active duty from 2007 to 2010 but did not mention his left wrist. He stated that he did not complain about his left wrist in service because he was a Medic and it would look bad. He reported that he was never seen for his wrist condition since his initial separation from service in 2006. He also stated that he did not mention anything about his left wrist on his re-enlistment examination in 2007. The Board also notes that no left wrist conditions were listed in the Veteran’s separation examination in 2009. He stated he was always just sore and stiff with lifting activity. Medical treatment records indicate that the Veteran was seen at Portland VA for his elbow but there is no mention of his wrist. The Veteran was afforded a VA examination in December 2010. The Veteran reported that his left wrist has intermittent pain that is activity related. It feels weak and is aggravated with lifting, grasping and twisting type movements. He said that he experiences flare-up type episodes on an average of two times a week and it just takes a few minutes after stopping the offending activity for his pain to resolve. The Veteran utilizes rest, stretching, and ibuprofen as alleviating factors. He is able to care for his activities of daily living. He has not had any incapacitating episodes of missed any time from active service within the past 12 months. An x-ray of his left wrist showed a left wrist sprain. The examiner opined that he would expect that the Veteran “would have mild weakness, mild fatigability, and no loss of coordination secondary to repetitive activity, painful flare-up episodes.” The examiner reported that there is no notation of the Veteran’s left wrist condition on his separation examinations. In discussion with the Veteran, the Veteran stated that he was a Medic and he took care of his own needs. He said that his left wrist began having pain and weakness, but he does not recall any specific injurious episode and he did not get seen for wrist conditions in service. The examiner opined that “I am not able to resolve the issue of service connection without any documentation. I have no reasons to doubt the Veteran's statement. However, without any documentation, regarding the left wrist, I would be resorting to mere speculation.” A July 2015 medical note indicated that the Veteran exercises on a typical day using free weights and flash cycle training. The Veteran was afforded another VA examination in May 2019 for wrist conditions. The Veteran was diagnosed with a left wrist contusion. On examination, the Veteran’s left wrist had minimal findings with tenderness on palpation only and full range of motion and strength. When asked about current treatments, the Veteran stated that he just rests and does not use his left wrist very much. He described his left wrist condition as a sore ache on the lateral aspect of the wrist with lifting and carrying. The Veteran reported that he has full activities of daily living (ADLs) and no locking, clicking, popping or swelling in the wrist. He only noted an ache laterally. The Veteran reported flare-ups and stated that lifting and carrying causes increased aches in the lateral aspect of his left wrist. The Veteran also reported having functional loss/impairment in the form of an ache. He denied having loss in range of motion. The examiner reported a normal range in motion for the Veteran’s left wrist with palmar flexion of 80 degrees, dorsiflexion of 70 degrees, ulnar deviation of 45 degrees and radial deviation of 20 degrees. The Veteran denied pain on examination. There was no additional loss of function or range of motion after three repetitions. The examiner noted that the Veteran had a mildly tender lateral wrist on palpitation. Muscle strength testing was normal. The examination was negative for ankylosis and degenerative or traumatic arthritis. The examiner opined that the Veteran had mild evidence, on objective exam, of pain on palpation, and there was no evidence of pain on active or passive range of motion or weightbearing motion on the left wrist. The examiner opined that the Veteran’s left wrist disability was “at least as likely as not (50% or greater probability) incurred in or caused by the claimed in-service injury, event or illness.” The rationale offered was that there is no evidence that the Veteran was ever seen for his left wrist disability. He states that the left wrist condition started as pain that developed over time from lifting in the service. The examiner noted that given that the Veteran had the opportunity while in active duty and with over a decade of opportunity to be seen for his left wrist, but has not been seen by a medical professional, and there is no chronicity found with documentation. Therefore, the Veteran’s left wrist disability is not at least as likely as not related to any in-service activity or injury that was not documented. The examiner also noted that the Veteran’s disability was consistent with a minor contusion, which is not consistent with trauma in service or chronic strain from lifting as he would be expected to have limited motion or painful motion and this was not found on examination. The examiner provided a second medical opinion in April 2020 to correct the May 2019 medical opinion. The examiner clarified that “box A was checked by mistake. The opinion given should have been correctly checked box (b) the claimed condition was less likely than not incurred in or caused by in-service event or injury or activity. This is further supported in the rationale portion of the opinion and supported by exam and review record. To clarify this is a negative opinion.” There is nothing to suggest that the examiner who conducted the May 2019 examination report and April 2020 addendum negative nexus opinion, was not competent to provide those medical opinions. Therefore, the Board finds the VA examinations and associated medical opinion adequate and probative. The December 2010 VA examination is also probative, but the Board notes that the examiner could not provide a medical opinion without mere speculation. Therefore, the leading medical opinions of record are the ones provided as part of the May 2019 and April 2020 VA examination and opinions. Although the Board finds the Veteran credible in the reporting of is symptoms relating to his wrist condition, and that his wrist condition started in service, the Veteran’s lay statements are inconsistent with the other evidence in the record. Specifically, there is no indication in the Veteran’s STRs or post-service medical treatment records that he complained of or sought treatment for a left wrist disability. As noted by the May 2019 VA examiner, the Veteran had, on numerous occasions, the opportunity to seek treatment for or complain about his left wrist disability, and he in fact complained about and sought treatment for other disabilities, but he did not do the same for his claimed left wrist disability. Therefore, there is no continuity in symptomatology from the Veteran’s final separation from service to the present, and the evidence does not support the finding that the Veteran’s left wrist disability was incurred in service. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. Given that no ultimate, material issues are in equipoise, that doctrine is not applicable in the instant appeal. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49. Accordingly, the Board finds that the preponderance of evidence is against a finding that the Veteran’s left wrist disability was incurred in service. Therefore, the claim for service connection for a left wrist disability must be denied. 38 U.S.C. § 5107; Gilbert, 1 Vet. App. at 49. Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. White, 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.