Citation Nr: 21062685 Decision Date: 10/08/21 Archive Date: 10/08/21 DOCKET NO. 16-30 849 DATE: October 8, 2021 ISSUES 1. Entitlement to service connection for a low back disorder. 2. Entitlement to service connection for a right hip disorder. 3. Entitlement to service connection for a bilateral knee disorder. 4. Entitlement to service connection for bronchitis (hereinafter, respiratory disability). ORDER Entitlement to service connection for a lumbosacral strain is denied. Entitlement to service connection for a right hip disorder is denied. Entitlement to service connection for a bilateral knee disability is denied. Entitlement to service connection for a respiratory disability, to include bronchitis is granted, subject to the laws and regulations governing the payment of monetary benefits. FINDINGS OF FACT 1. The Veteran's current lumbosacral strain was not manifest during service and is otherwise unrelated to the Veteran's active service. 2. The Veteran's right hip disorder did not manifest in service and is otherwise unrelated to the Veteran's active service. 3. The Veteran's bilateral knee disability did not manifest in service and is otherwise unrelated to the Veteran's active service. 4. The Veteran's respiratory disability, to include bronchitis, cannot be satisfactorily disassociated from the Veteran's active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a lumbosacral strain have not been met. 38 U.S.C. §§ 1101, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for a right hip disorder have not been met. 38 U.S.C. §§ 1101, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The criteria for service connection for a bilateral knee disability have not been met. 38 U.S.C. §§ 1101, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 4. Resolving all doubt in the Veteran's favor, the criteria for entitlement to service connection for a respiratory disability, to include bronchitis have been met. 38 U.S.C. §§ 1110, 1154(b), 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1985 to April 1990 and from February 1991 to June 1991. These issues come before the Board of Veterans' Appeals (Board) on appeal of from a May 2015 rating decision issued by a U.S. Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, July 2020 and May 2021, the Board remanded the claims on appeal for additional development. The case is again before the Board for appellate review. Based on the evidence of record, the Board has recharacterized the Veteran's claim of entitlement to service connection for bronchitis as entitlement to service connection for a respiratory disability, to include bronchitis. Service Connection In order to obtain service connection under 38 U.S.C. §§ 1110, 1131 and 38 C.F.R. § 3.303 (a) a Veteran must satisfy a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so- called 'nexus' requirement. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Entitlement to service connection for a low back disorder. The Veteran contends she is entitled to service connection for a lower back disability. During her November 2016 Decision Review Officer Hearing (DRO), the Veteran explained that she first suffered from back problems during enlistment due to the rigorous training, and from long days sitting in a desk chair typing; upon complaining, she was told to utilize Motrin and water. See November 30, 2016 transcript, pgs. 2-3 See also, June 9, 2016 VA Form 9 re: long marches, up to 15 miles with extremely heavy gear. Following service, the Veteran explained, her back continued to hurt and she was forced to use over-the-counter pain medications and massage chairs for pain relief. See November 30, 2016 transcript, pgs. 3-4 The evidence of record reflects that the Veteran was diagnosed with a lumbosacral spine disorder in 2017. See June 7, 2017 Back Conditions examination, pg. 2 re: diagnosis of lumbosacral strain. The Veteran's service treatment records are silent regarding any complaint, treatment or diagnosis for a low back condition. Post service records show that the Veteran was treated for musculoskeletal neck strain. See January 28, 1997 treatment record (Family Urgent Care). Post service also record also show that the Veteran was in a motor vehicle accident on January 27, 1997 and struck from behind. The Veteran was seen at the ER on the day of the accident and x-rays were negative. See March 3, 1997 treatment records (Family Urgent Care). With respect to a nexus to service, the Veteran has been afforded VA examinations and medical opinions in June 2017, October 2020, March 2021 and August 2021. Each examiner rendered a negative nexus opinion to service. The Board found the June 2017, October 2020, and March 2021 examinations inadequate because the examiners discounted the Veteran's descriptions of her in-service back injury and contentions solely of the basis of a lack of contemporaneous medical records documenting the injury. Hence, the Board discussion and analysis below will focus on the August 2021 medical opinion with respect to the nature and etiology of this Veteran's lower back disability. As will be further explained below, because the August 2021 examiner fully considered the Veteran's lay descriptions of her in-service back injury in the absence of contemporaneous medical records documenting the injury, the Board finds this medical opinion adequate for adjudication purposes. Pursuant to the Board's May 2021 remand, the Veteran was afforded an August 2021 Medical Opinion to determine the nature and etiology of her low back disability. After review of the Veteran's claims file, including service treatment records, post-service treatment records, the Veteran's medical history and lay descriptions of her injury, the examiner opined that it is less likely than not that the diagnosed lumbosacral strain was incurred in or caused by military service. The physician examiner provided the following rationale to support this conclusion: The Veteran had two periods of service, from September 17, 1985 to April 6, 1990 and from February3, 1991 to June 22, 1991. The entry examination at the beginning of the second active-duty period was normal. Under the presumption of soundness, the Veteran had no significant physical impairment at the beginning of the second active-duty period thereby indicating that any back issues experienced during the first active-duty period were transient. The Veteran asserts that she was told to take Motrin for back pain in service and has suffered continuous back pain since service. While the Veteran is competent to describe her symptoms during service as a layperson, she is not able to determine the cause of those symptoms. As lay persons friends and family are competent to describe what the Veteran told them or what they personally witnessed, but they also are not able to provide a diagnosis or determine the etiology of symptoms or observations. The circumstances of back pain the Veteran experienced in service was as a fit 1824-year-old. Such back pain is more likely muscular due to overwork, such as hiking with full gear as described by the Veteran. After a motor vehicle accident in 1997 she described different back pain consistent with muscular injury in the accident (Family Urgent Care 3/3/97). Current back pain from chronic lumbosacral strain is more likely due to obesity leading to altered posture and overload of spinal musculature compounded by deconditioning of musculature. Service records provided do not document an in-service injury, activity, event, illness, or condition likely to result in or predispose to development of longterm back pathology or the diagnosed chronic lumbosacral strain. See August 5, 2021 Medical Opinion, pgs. 3-4. Analysis In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The Board finds the August 5, 2021 Medical Opinion highly probative for the following reasons: First, the examiner noted review of the Veteran's claims file, including service treatment, post-service treatment and her medical history. Second, the examiner carefully considered the Veteran's lay descriptions of complaints of back pain during service, evaluating whether these lay descriptions (in the absence of in-service treatment records) link the Veteran's current low back disability to service. Third, the examiner provided well-reasoned rationale for the conclusion reached, referencing data points and pertinent evidence of record to support her opinion. A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In this case, the examiner opined against any connection between the Veteran's current lumbosacral strain and any in-service complaints of back pain or injury. The Board also highlights that the August 2021 examiner cited to appropriate medical principles in support of her opinion. Addressing the nature and etiology of this Veteran's back disability, the examiner explained that the circumstances of back pain the Veteran experienced in service was as a fit 1824-year-old. The examiner further explained that such back pain is more likely muscular due to overwork, such as hiking with full gear as described by the Veteran. Continuing her discussion on the etiology of this Veteran's back disability, the examiner explained that "after a motor vehicle accident in 1997 she described different back pain consistent with muscular injury in the accident (Family Urgent Care 3/3/97). Current back pain from chronic lumbosacral strain is more likely due to obesity leading to altered posture and overload of spinal musculature compounded by deconditioning. Service records provided do not document an in-service injury, activity, event, illness, or condition likely to result in or predispose to development of longterm back pathology or the diagnosed chronic lumbosacral strain. See August 5, 2021 Medical Opinion, pgs. 3-4. Because the August 2020 examiner fully considered the Veteran's lay descriptions of in-service back pain and injury, while addressing the likely etiology of this Veteran's lumbosacral strain, the Board finds this opinion both probative and persuasive as to the nature and etiology of this Veteran's current back disability. The Veteran has clearly expressed her own belief in a nexus, but as a layperson, she lacks the necessary training and information to formulate a competent opinion on the etiology of her current disability. A causal opinion here lies outside the Veteran's competence. Layno v. Brown, 6 Vet. App. 465 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Therefore, the Board does not assign any probative value to the Veteran's statements regarding the etiology of her back disability and finds her assertions linking her current low back disability to active-duty service unpersuasive. The Board also notes that the earliest evidence of a back pain post service was in 1997, in connection with a motor vehicle accident. See March 3, 1997 treatment records (Family Urgent Care). Based on a review of the lay and probative medical evidence of record, the Board finds that the Veteran's current lumbosacral strain was not manifest during service and is otherwise unrelated to service. For the foregoing reasons, the Board finds that the preponderance of the evidence is against the claim. The claim for entitlement to service connection for lumbar sacral strain must be denied. There is no reasonable doubt to be resolved. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for a right hip disorder; and bilateral knees. The Veteran contends that she is entitled to service connection for a right hip disorder and a bilateral knee disability. The Veteran explained at her November 2016 Regional Office DRO hearing, that she suffered from pain and fluid buildup in her right hip due to holding her rifle in her right arm and carrying a heavy backpack throughout all of her training. The Veteran further explained in in her Regional Office hearing that she would not go to sick call for some of these conditions because it would reflect poorly on her in terms of the level of respect you get if you're hanging around sick bay. The Veteran further explained that she was a non-commissioned officer, and you didn't go to sick call as often as you should. See November 30, 2016 transcript, pgs. 9-11; See also October 23, 2014 Lay Correspondence re: lay assertion that right hip resulted from. strenuous physical fitness training. The Veteran stated that BAS just recommended that she take motrin or Tylenol as needed. With respect to her bilateral knee disability, she explained in her November 2016 Regional Office hearing that she had to have excess fluid drained from her knees while in service due to the long marches (she further explained that those records were missing in her service treatment records), and she still suffered from bilateral knee and right hip pain. See November 30, 2016 transcript, pgs. 17-18; October 23, 2014 Lay Correspondence re: assertion that she was treated for swollen knees in Okinawa Japan. See February 14, 2018. Correspondence re: photograph of a field meets during service in 1986 claiming knees were jarred as she participated in this meet. The Veteran's service treatment records are silent for any treatment, complaints or treatment for a right hip or bilateral knee condition. Pursuant to the Board's July 2020 Remand directives, the Veteran was afforded an October 2020 Hip and Thigh examination. The examiner found that there was no objective evidence to make a diagnosis or the claimed condition and rendered a negative nexus opinion to service. See October 13, 2020 Hip and Thigh Conditions examination, pgs. 1-3; See also, October 13, 2020 Medical Opinion, pgs. 4-5. Pursuant to the Board's May 2021 Remand Directives, the Veteran was afforded an additional addendum medical opinion in August 2021 regarding the nature and etiology of her hip disorder. After review of this Veteran's claims file, including service treatment records, post-service treatment records, medical history and the lay assertions, the physician examiner rendered a negative nexus to service. The August 2021 physician examiner provided the following rationale to support this conclusion: There is no pathology to render a diagnosis for a right hip condition at this time. Further, the Veteran statements that she had pain and "fluid buildup" in her right hip from holding her rifle in her right arm and carrying a heavy backpack throughout training are consistent with soft tissue trauma to the lateral hip, a condition that does not result in or predispose to long term hip pathology. The Veteran is competent to describe her symptoms during service, but as a lay person she is not able to determine the cause of those symptoms. As lay persons friends and family are competent to describe what the Veteran told them or what they personally witnessed, but they also are not able to provide a diagnosis or determine the etiology of symptoms or observations. The circumstances of hip pain the Veteran experienced in service as she describes them are consistent with self-limited soft tissue injury. The January 1991 re-enlistment exam indicates that at that time the Veteran was fit for military duty and under the presumption of soundness any previous hip conditions in her first active- duty period did not result in significant impairment (Morash. Report of Med Hx & Exam 24 Jan 1991). Neither active-duty period documented an in-service injury, activity, event, illness, or condition likely to result in or predispose to development of long-term hip pathology. In this case Veteran statements continuous hip pain since service must consider that over 30 years the cause of the hip pain is likely to have changed from a condition likely to affect a fit 24-year-old to other conditions likely to affect an obese 54-year-old. See August 5, 2021 Medical Opinion pgs. 2-3. With respect to the Veteran's bilateral knee disability, the Veteran was afforded an October 2020 Knee and Lower Leg Conditions examination to determine the nature and etiology of her disability. The examiner established that the Veteran had a diagnosis of patellofemoral pain syndrome. See October 13, 2020 Knee and Thigh Conditions examination, pg., 2. In a subsequent October 2020 Medical Opinion, the examiner rendered a negative nexus opinion towards service. See October 13, 2020 Medical Opinion, pgs. 4-5. Pursuant to the Board's May 2021 remand, the Veteran was afforded an additional addendum medical opinion in August 2021 regarding the nature and etiology of her bilateral knee disability. After review of the Veteran claims file, service treatment records, post service treatment records, medical history and lay assertions, the examiner rendered a negative nexus opinion towards service. The examiner opined that it is less likely than not that the diagnosed patellofemoral syndrome bilateral knee was incurred in or caused by military service. The examiner provided the following rationale to support this opinion: While the veteran asserts that she had excess fluid drained from her knees in service due to long marches and suffered continuous knee pain since service she is not able to provide a diagnosis for her symptoms. The Veteran is competent to describe her symptoms during service, but as a lay person she is not able to determine the cause of those symptoms. As lay persons friends and family are competent to describe what the Veteran told them or what they personally witnessed, but they also are not able to provide a diagnosis or determine the etiology of symptoms or observations. Patellofemoral syndrome does not cause knee swelling or require that fluid be drained from the knee. The Veteran was at most 24 years of age when she left military service and as evidenced from the January 1991 exam was fit for military service (Morash. Report of Med Hx& Exam 24 Jan 1991). It is therefore likely that knee pain she claims to have experienced during service was due to strain associated with military activities. Such knee strain does not result in or predispose to development of the currently diagnosed patellofemoral syndrome. Patellofemoral pain syndrome is the result of improper tracking of the patella within the trochlear groove (Up to Date, Patellofemoral pain). Overload of the knee extensor mechanism a central factor in development of patellofemoral syndrome (Up to Date, Patellofemoral pain). This overload is now more likely the result of the Veteran's long history of obesity. The service records provided do not document an in-service injury, activity, event, illness, or condition likely to result in or predispose to development of long-term knee pathology or the diagnosed patellofemoral syndrome. Thus, reported long term knee pain from service onward has transitioned from a cause of knee strain during service and shortly after to patellofemoral syndrome as the Veteran progressively gained weight and thereby overloaded the knees. See August 5, 2021 Medical Opinion, pgs. 1-3. Analysis The Board finds the August 2021 examination report highly probative. The August 2021 examiner noted the Veteran's medical history and lay assertions and opined against any connection between the Veteran's current hip disorder and service. First, it important to note that the examiner determined that there is no pathology to render a diagnosis for a right hip condition at this time. Second, the examiner explained that the circumstances of hip pain the Veteran experienced in service as she describes them are consistent with self-limited soft tissue injury. After referencing data points and pertinent evidence of record (e.g., January 1991in-service physical examination), the examiner determined that neither active-duty period documented an in-service injury, activity, event, illness, or condition likely to result in or predispose to development of long-term hip pathology. See August 5, 2021 Medical Opinion pgs. 2-3. The August 2021 physician examiner also opined that the Veteran did not suffer from bilateral knee disability that was related to service or a service-connected disability. The examiner explained that patellofemoral syndrome does not cause knee swelling or require that fluid be drained from the knee. Discussing pertinent evidence of record, the examiner explained that the Veteran was at most 24 years of age when she left military service and as evidenced from the January 1991 exam was fit for military service (Morash. Report of Med Hx& Exam 24 Jan 1991). Addressing the nature and etiology of her knee disability, the examiner explained that it is therefore likely that knee pain she claims to have experienced during service was due to strain associated with military activities. Such knee strain does not result in or predispose to development of the currently diagnosed patellofemoral syndrome. Id. at pg. 3. A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The Board observes that the examiner cited to appropriate medical principles in support of her opinion addressing the Veteran's right hip and bilateral knee claim. In this case, the Board does not assign any probative value to the Veteran's statements regarding the etiology of her claimed hip disability or bilateral knee disabilities as she is not competent to opine on the etiologies of complex medical issues such as soft-tissue injury, patellofemoral syndrome or the long-term pathology of hip pain. See Layno v. Brown, supra. Hence, the Board finds the Veteran's assertions linking her right hip disorder and bilateral knee disability to active-duty service unpersuasive. Because the examiner fully considered the Veteran's lay descriptions of an in-service hip injury associated with fluid build-up from carrying a rifle during service and considered the Veteran's lay descriptions of fluid being drained from her knees from long marches during service, the Board finds this August 2021 examination and medical opinion both probative and persuasive as to the nature and etiology of her hip and bilateral knee disability. Based on a review of the lay and probative medical evidence of record, the Board finds that the Veteran's current right hip disorder and bilateral knee disabilities did not manifest in service and are otherwise unrelated to service. For the reasons explained above, the Board finds that the preponderance of the evidence is against the claims. The claims for entitlement to service connection for a right hip disorder and patellofemoral syndrome of the bilateral knees must be denied. There is no reasonable doubt to be resolved. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Entitlement to service connection for a respiratory disability, to include bronchitis. The Veteran contends she suffered from bronchitis in service and has continued to suffer from it since service. She contends (for example, in a December 22, 2014 statement) this may also be due to asbestos exposure in service. In her November 2016 DRO hearing the Veteran stated that she did go to sick call during service for bronchitis, beginning in April of 1990. The Veteran states that she still has a lot of trouble with her ears, nose and throat and was prescribed albuterol inhaler. The Veteran also stated that she believed she was exposed to asbestos at Camp Lejeune. See also, November 30, 2016 DRO transcript, pgs. 19-22. The Veteran further states that she was frequently prescribed an antibiotic during service, just about every other month. The Veteran states that she has had this condition her entire career. See August 19, 2003, VA Form 21-4138, Statement in Support of Claim; See also October 23, 2014 Lay Correspondence. See also, June 9, 2016 VA Form 9. The Veteran's service treatment records document acute attacks of bronchitis, as do her current VA medical records. See e.g., February 5, 1986 STR reports that the Veteran was treated for a viral syndrome, bronchitis; April 8, 1988 STR report the Veteran was treated for complaints of coughing up phlegm, difficulty breathing, diagnosed and treated for bronchitis; January 27, 1989 re-enlistment examination, the Veteran is assessed for bronchitis. See January 27, 1989 Report of Medical Examination. Post service, April 1, 2005 treatment records show that she was diagnosed with bronchitis. March 25, 1997 treatment records show that the Veteran was treated for bronchitis (Family Urgent Care); See also March 29, 1997 treatment records re: assessment, bronchitis. A September 12, 2019 treatment records reports that the Veteran uses over-the-counter albuterol inhalers for her respiratory condition. It was reported that the Veteran feels shortness of breath and has mild wheezing. Examinations During the course of this appeal, the Veteran has been afforded examinations and medical opinions in June 2017, September 2019, October 2020 and August 2021 to determine the nature and etiology of her respiratory disability. The Board will discuss each examination and medical opinion for purposes of adjudication. In the June 2017 Respiratory Conditions examination, the examiner determined that the Veteran did not have a respiratory condition. See June 7, 2017 Respiratory Conditions examination, pgs. 1-6. The examiner also reported that a Chest x-ray performed June 12, 2017 was within normal limits. Id. at pg. 9; See also, June 12, 2017 Radiology Report (Chest). With respect to pulmonary function testing, the examiner reported that pulmonary function testing indicates: "It is a technically adequate simple spirometry pre and post, which is normal. There is no response to albuterol. There is moderate reduction in diffusion capacity. There is no comparative pulmonary function study for review. Id. at pg. 11; See also June 12, 2017 Pulmonary Function Report. The June 2017 examiner reported that the Veteran respiratory condition does not impact her ability to work. See June 2017 Respiratory Conditions examination pg. 11. The examiner concluded that while there may have been a diagnosis of bronchitis in the past, based on the current physical examination, pulmonary function testing, and diagnostic imaging, a diagnosis of bronchitis cannot be supported. Id. at 11. In a June 7, 2017 medical opinion, the examiner opined that he claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that "there are service treatment records from 1989 that indicate the veteran was treated for episodes of bronchitis during military service. The claims file also contains civilian treatment records from Family Urgent Care revealing a diagnosis of bronchitis in 1997. There are no more recent episodes of bronchitis documented in the claims file. This would suggest that the episodes of bronchitis are individual acute episodes. The Veteran currently does not meet diagnostic criteria for bronchitis by way of diagnostic imaging, pulmonary function testing, or physical examination. Therefore, there is no basis by which to establish a claim for bronchitis associated with continuation of treatment for bronchitis during service". See June 7, 2017 Medical Opinion, pg. 3. Pursuant to the Board's October 2018 remand, the Veteran was afforded a September 2019 Respiratory Conditions examination. the examiner reviewed the Veteran's claims file, including but not limited to the Veteran's service treatment records, medical history and post-service treatment records. It is important to note that the examiner reviewed military records that show that the Veteran was treated for bronchitis. The examiner reported that the Veteran is prescribed an antibiotic for her respiratory condition (Clindamycin) 2-3 times per year, mostly in the winter months. See September 10, 2019 Respiratory Conditions examination, pgs. 1-3. The examiner determined that the Veteran did not have a respiratory condition. Id. at pgs. 1-10. The examiner indicated that the Veteran's September 17. 2019 Chest X-Ray was normal. It was reported that there are small para-hilar calcification with no clinical significance. Id. at 10. The examiner reported that the Veteran's respiratory condition did not impact her ability to work. The examiner reported that there was no objective evidence was found on the examination to warrant a diagnosis of the claimed condition. Id. at pgs. 11-12. In a September 2019 Medical Opinion, the examiner rendered a negative nexus opinion to service, reasoning that there is no diagnosis of any lung condition based on today's examination and Chest X-Ray. The treated bronchitis was only in acute setting and there is no evidence that there is chronicity. See September 10, 2019 Medical Opinion, pgs. 1-2. Pursuant to the Board's July 2020 Board remand, the Veteran was afforded an October 2020 Respiratory Conditions examination and medical opinion. See October 13, 2020 Respiratory Conditions examination. The examiner noted review of the Veteran's claims folder. The examiner reported that the Veteran has a diagnosis of chronic bronchitis. The examiner reported the date of diagnosis in 2016. See October 13, 2020 Respiratory Conditions examination, pgs. 2, 4 & 12. The examiner noted review of the Veteran's medical history, and daily use of inhaled medications, daily. The examiner reported the Veteran's respiratory condition required the use of inhaled medications and daily use of inhalational anti-inflammatory medications. Id. at pgs. 3-4. The examiner reported that the Veteran's bronchitis occasionally becomes severe enough to miss work to seek treatment and recover. Id. at 12. The examiner rendered a negative nexus opinion reasoning that "additional undated record indicates bronchitis; however, no mention is made of any chronic or recurrent bronchitis, and one or 2 episodes of bronchitis over the course of service time is expected, and does not represent likelihood of a chronic condition. Recent records and current HPI indicate chronic bronchitis, which most likely developed after service. Regarding other etiologies for her bronchitis, this is not relevant to the question of service connection, since it is answered by the absence of service treatment records indicating such. Bronchitis has many possible causes, which may be reviewed in any pathophysiologic textbook regarding the subject". See October 13, 2020 Medical Opinion. Pursuant to the Board's May 2021 Remand, the Veteran was afforded an additional Respiratory Conditions Medical Opinion in August 2021. The physician examiner rendered a negative nexus opinion to service. The examiner provided the following rationale to support this opinion: "Past and recent records indicate acute intermittent bronchitis in the setting of viral upper respiratory infections. Acute intermittent bronchitis due to bronchitis in service: There is no pathology to render a diagnosis for a chronic respiratory condition. The records provided, history, claimant statements, and diagnostic testing are consistent with episodes of acute bronchitis associated with upper respiratory infections. It is less likely than not that the episodes of acute intermittent bronchitis are proximately due to or the result of military service. Acute bronchitis is one of the most common conditions encountered in clinical practice and accounts for approximately 10 percent of ambulatory care visits in the United States, or 100 million visits per year (Harris et al, Ann Intern Med. 2016;164 (6):425). The most common cause of acute intermittent bronchitis is viral infection (Up to Date, Acute bronchitis in adults). Acute bronchitis resolves in generally 1-3 weeks without complications (Up to Date, Acute bronchitis in adults). The acute bronchitis the Veteran had in service therefore cannot result in or predispose to development of recurrence of this very common condition caused by ubiquitous upper respiratory viruses. While the Veteran is competent to describe her symptoms during service, as a lay person she is not able to determine the cause of those symptoms. As laypersons friends and family are competent to describe what the Veteran told them or what they personally witnessed, but they also are not able to provide a diagnosis or determine the etiology of symptoms or observations. The totality of the evidence indicates diagnosis of acute bronchitis episodes as indicate". See August 5, 2021 Medical Opinion. Analysis After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for a respiratory disability, to include bronchitis is warranted. The Board underscores that the October 2020 Respiratory Conditions examiner reported the Veteran's diagnosis as chronic bronchitis, requiring the use of inhaled medications and daily use of inhalational anti-inflammatory medications. This same examiner reported that the Veteran's bronchitis occasionally becomes severe enough to miss work to seek treatment and recover. See October 13, 2020 Respiratory Conditions examination, pgs. 2-4 & 12. Upon review of the examinations and medical opinions of record, lay testimony, service treatment and post service treatment records, the Board finds that the Veteran's respiratory condition has not been satisfactorily disassociated with service. The Board observes that each VA examiner notes that the Veteran had a diagnosis of bronchitis during service. The issue for each examiner has been one of chronicity during and after service. To this point, the Board notes that the Veteran states that she was frequently prescribed an antibiotic for her respiratory condition during service, just about every other month. Additionally, the Veteran reported that she has had this condition her entire career. See August 19, 2003, VA Form 21-4138, Statement in Support of Claim; See also October 23, 2014 Lay Correspondence; June 9, 2016 VA Form 9; See also, November 30, 2016 DRO, transcript, pgs. 19-22. Additionally, the Board is cognizant that pain alone, even without an underlying pathology or diagnosis, can constitute a disability under VA law where such pain results in functional impairment. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). While the holding in Saunders does not apply in the case, the Court recently held that Saunders is not limited to pain, such that a disability for VA purposes includes any condition that results in functional impairment of earning capacity. Martinez-Bodon v. Wilkie, 32 Vet. App. 393 (2020). To this point, Board reiterates that the October 2020 examiner reported that the Veteran's respiratory condition occasionally becomes severe enough for her to miss work to seek treatment and recover. See October 13, 2020 Respiratory Conditions examination, pg. 2. Otherwise stated, the Board finds that the symptoms of this Veteran's respiratory condition rise to the level of a functional impairment of earning capacity. In summary, considering the Veteran's in-service diagnosis of bronchitis, lay testimony regarding in-service treatment, post-service treatment records showing a diagnosis and treatment for bronchitis, combined with the Board's finding that the Veteran's respiratory condition rises to the level of functional impairment of earning capacity, the Board finds that the Veteran's respiratory disability, to include bronchitis has not been satisfactorily disassociated from the Veteran's active service. The Board also notes that where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA will give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); See Lynch v. McDonough, No. 2020-2067, 2021 U.S. App. LEXIS 16533, at *10 (Fed. Cir. June 3, 2021). Here, with regard to the question of whether the Veteran's current respiratory disability initially manifested during service, such a balance of evidence exists. Resolving reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for a respiratory disability, to include bronchitis are met. Michael A. Pappas Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Little, 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.