Citation Nr: 21063510 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 17-13 622 DATE: October 14, 2021 ORDER Entitlement to service connection for Chronic Fatigue Syndrome (CFS) is denied. Entitlement to service connection for left ear hearing loss is denied. Entitlement to service connection for right ear hearing loss is denied. Entitlement to service connection for a right knee disability is denied. FINDINGS OF FACT 1. The Veteran served on active duty in the Southwest Asia Theater during the Persian Gulf War; however, the preponderance of the evidence is against finding that the Veteran's reported symptoms are manifestations of an undiagnosed illness related to the Veteran's Gulf War service. 2. The most probative evidence of record shows that left ear hearing loss was not manifested during, or a result of, active military service nor did it manifest within a year of separation. 3. The most probative evidence of record shows that right ear hearing loss was not manifested during, or a result of, active military service nor did it manifest within a year of separation. 4. The most probative evidence of record shows that the Veteran's right knee disability did not have its onset during service and is not attributable to his service. CONCLUSIONS OF LAW 1. The criteria for service connection for an undiagnosed illness or other chronic qualifying disability pursuant to 38 U.S.C. § 1117, claimed as Chronic Fatigue Syndrome, have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2020). 2. The criteria for service connection for left ear hearing loss have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1154, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2020). 3. The criteria for service connection for right ear hearing loss have not been met. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1154, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2020). 4. The criteria for entitlement to service connection for a right knee disability have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran has active duty from September 1984 to September 1988 and from January 1989 to June 1992. This matter is before the Board of Veterans' Appeals (Board) on appeal from May 2013 and July 2013 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The issues of entitlement to service connection for left ear hearing loss and CFS were initially denied by the Board in a December 2019 decision. The Veteran appealed this decision to the United States Court of Appeals for Veterans Claims (Court), and, in October 2020, the Veteran and the Secretary of Veterans Appeals (Secretary) filed a Joint Motion for Partial Remand (JMPR). This motion was granted in an October 2020 Court order. In accordance with the October 2020 JMPR, the Board remanded the claims of entitlement to service connection for CFS, left ear hearing loss, right ear hearing loss, and right knee disability in March 2021. The case is again before the Board. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). In general, service connection requires (1) evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 382 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for any disease or injury diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303 (d). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by evidence to the contrary. 38 C.F.R. §§ 3.307, 3.309. Bilateral sensorineural hearing loss is an organic disease of the nervous system and thus falls within 38 C.F.R. § 3.309 (a). See VA Under Secretary for Health Memorandum (Oct. 1995); see also Fountain v. McDonald, 27 Vet. App. 258 (2015) (stating, "the Secretary has made clear that sensorineural hearing loss is considered subject to 3.309(a) as an '[o]rganic disease[ ] of the nervous system'".). Alternatively, for the showing of chronic disease in service, there is a required combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. §§ 3.303 (b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Continuity of symptomology is required only where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. A Veteran is competent to describe symptoms that he experienced in service or at any time after service when the symptoms he perceived or experienced, were directly through the senses. 38 C.F.R. § 3.159; Layno v. Brown, 6 Vet. App. 465, at 469-71 (1994). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). VA must consider the competency of the lay evidence and cannot outright reject such evidence on the basis that such evidence can never establish a medical diagnosis or nexus. However, this does not mean that lay evidence is necessarily always sufficient to identify a medical diagnosis, but rather only that it is sufficient in those cases where the lay person is competent and does not otherwise require specialized medical training and expertise to do so; i.e., the Board must determine whether the claimed disability is a type of disability for which a layperson is competent to provide etiology or nexus evidence. See Davidson, 581 F.3d at 1316. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, incurrence, or disease. 1. Entitlement to service connection for Chronic Fatigue Syndrome (CFS) The Veteran asserts entitlement to service connection for chronic fatigue syndrome (CFS). Specifically, the Veteran contends that his claimed CFS was caused by breathing diesel fuel throughout his military career and breathing burning feces in Iraq. See March 2017 Notice of Disagreement. The Board notes that the Veteran served in the Southwest Asia theater of operations in support of Persian Gulf War. 38 C.F.R. § 3.317 (e). Under those provisions, service connection may be established for objective indications of a chronic disability resulting from an undiagnosed illness or illnesses, provided that such disability (1) became manifest in service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and (2) by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. To fulfill the requirement of chronicity, the illness must have persisted for six months. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317 (b). There must be objective signs that are perceptible to an examining physician and other non-medical indicators that are capable of independent verification. There must be a minimum of a six-month period of chronicity. There must be no affirmative evidence that relates the illness to a cause other than being in the Southwest Asia Theater of operations during the Persian Gulf War. If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98 (Aug. 3, 1998). For purposes of this section, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117 (d) warrants a presumption of service-connection. 38 C.F.R. § 3.317 (a)(2)(i). For purposes of this section, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). For purposes of this section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317 (a)(3). Compensation shall not be paid under this section, however, if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317 (c). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury event or disease. The Veteran has reported multiple symptoms, including respiratory conditions, shortness of breath, hives, calf pain, hip pain, sleep impairment and difficulty concentrating. See July 2021 VA Examination Report. The Veteran is competent to describe his ongoing symptoms, in-service duties, and the occurrence of ongoing symptoms, and to this extent, these statements are credible. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). A review of the medical evidence of record does not reflect that the Veteran suffered from fatigue, headaches, respiratory issues, joint aches, and difficulty sleeping due to an undiagnosed illness, at any time during the appeal period. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Rather, his reported symptoms have been clinically attributed to service- and non-service-connected disabilities. January 1985 service treatment records (STRs) note the Veteran complained of an inability to fully expand his lungs since boot camp. The STRs note a history of similar episodes prior to boot camp. The Veteran's November 1991 separation examination does not note any sleep or fatigue issues and the Veteran denied frequent trouble sleeping. A November 2012 VA examination noted the Veteran's contention that exposure to dust and burning refuse during service in the Persian Gulf caused shortness of breath. The Veteran stated that his shortness of breath has not worsened since discharge and he has not sought medical treatment. The examiner diagnosed slightly overinflated lungs likely due to chronic obstructive pulmonary disease (COPD) with no evidence of acute lung infiltrates. A November 2012 VA Gulf War examination noted that the Veteran claimed respiratory, back and neck conditions, knee and lower leg, and headaches secondary to Southwest Asia exposure. The examiner noted a diagnosis for chronic fatigue which had no established etiology and the examination report indicated the Veteran reported not sleeping which will cause fatigue, thus the Veteran does not meet the diagnostic criteria for CFS or a sleep disorder. The examination report noted that there were no chronic disability patterns found in any of the Veteran's medical conditions and that all medical conditions have a clear and specific etiology and diagnosis. The examiner stated that there were no issues or medical conditions that are the result of, or were caused by, environmental exposures in Southwest Asia. The Board notes that the March 2021 remand found the November 2012 examination inadequate due to the opinion by the examiner, as it was unclear whether the Veteran's chronic fatigue had an etiology. In accordance with the March 2021 remand, the Veteran was afforded a VA examination in July 2021. The VA examiner reported that the Veteran does not have a current diagnosis of CFS. The Veteran reported a symptom onset in 1991, right after leaving Desert Storm, noticing fatigue, headaches, no energy, joint aches, and difficulty sleeping. The Veteran further reported that ten to 15 years later he started following up on his complaints, leading to diagnoses of degeneration in the joints, tension headaches, and anxiety. The VA examiner noted that a chest x-ray showed some COPD. Following an examination, the VA examiner opined that the Veteran's CFS is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of this opinion, the VA examiner reasoned that the Veteran has diagnoses related to musculoskeletal complaints (degenerative arthritis diagnosis) and headaches (related to tension). Furthermore, shortness of breath can be explained with COPD, hives were reported in childhood and resolved per subjective report, calf pains are related to feet per subjective report and with podiatry shoe inserts, and hip pains, per subjective report, as being related to back. None the less, all of the Veteran's symptoms combined do not fall into the category to meet VA criteria for a diagnosis of CFS. The VA examiner finally stated that none of the Veteran's diagnoses or complaints are related to any exposure during service while in Southwest Asia. The VA examiner could not opine as to the Veteran's sleep disturbances and difficulty concentrating complaints as they were being worked up with a sleep study. The Veteran completed a sleep study in June 2021. The Veteran reported snoring, restless sleep, and night sweats. Following the study, the physician reported moderate probability of obstructive sleep apnea (OSA) as well as irregular sleep wake cycle due to shift work related circadian rhythm disturbance and insufficient sleep. The physician further reported persistent night sweats in the context of smoking. The Board notes that the Veteran expressly stated that he suffered from CFS due to service in the Persian Gulf. See March 2017 Form 9. As reflected above, the clinical evidence of record indicates that the Veteran has not been diagnosed as having CFS during any period of the claim. Rather, the most probative evidence, particularly the VA examinations and treatment records, indicate that the Veteran does not meet the criteria for a diagnosis of CFS. Thus, service connection is not warranted for that disability. In addition, the most probative evidence of record, particularly the clinical evidence, indicates that the Veteran's symptoms of fatigue are not attributable to an undiagnosed illness resulting from his service in the Southwest Asia theater of operations during the Gulf War. Rather, his fatigue was noted to be due to his sleep apnea. See June 2021 VA Treatment Record. Furthermore, the Veteran's reported breathing problems, migraines, hives, and joint pain are all diagnosed disabilities and not attributed to Gulf War exposure. See June 2021 VA Examination Report. Although the Veteran served during the Persian Gulf War, he cannot establish service connection for an undiagnosed illness under 38 C.F.R. § 3.317, because there is no indication of an undiagnosed illness. As noted above, the Veteran has diagnoses of COPD, hives, tension headaches, moderate obstructive sleep apnea, and degenerative arthritis, which reflect the predominant disability picture and contemplate his symptomology. Further, COPD, hives, headaches, sleep apnea, and degenerative arthritis are not diagnosable chronic multisystem illnesses with an unexplained etiology and are not attributed to the Veteran's exposure to environmental hazards during the Gulf War. The Board further notes that the Veteran is currently service-connected for degenerative arthritis of the lumbar spine, right fifth metatarsal injury, tinnitus, degenerative arthritis of the cervical spine, and tension headaches. While the Veteran may believe that he has an undiagnosed illness or a medically unexplained chronic multisymptom illness, he is not competent to provide a diagnosis in this case. The issue is undoubtedly medically complex, as it requires the ability to interpret complicated diagnostic medical testing and understand the interaction between multiple pathologies. The Veteran is not competent to draw conclusions such as this. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the medical evidence in this case. Thus, because the preponderance of the evidence shows that Veteran does not have an undiagnosed illness or a medically unexplained chronic multisymptom illness attributable to his service in the Southwest Theater of Operations, the Board finds that service connection must be denied. The Board has duly considered the benefit-of-the-doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim, so that doctrine is not applicable. 2. Entitlement to service connection for left ear hearing loss 3. Entitlement to service connection for right ear hearing loss The Veteran asserts entitlement to service connection for bilateral hearing loss. Specifically, the Veteran contends his hearing loss is due to his hazardous noise exposure in-service, first noticed in 1992 at discharge. See June 2021 VA Examination Report. The VA considers impaired hearing to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; the thresholds for at least three of these frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC test are less than 94 percent. 38 C.F.R. § 3.385. For service connection, in-service noise exposure need not be the only source of acoustic trauma; it must only be a contributing source. The absence of in-service evidence of hearing loss disability during a Veteran's period of active duty is not fatal to a claim for service connection. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992). Competent evidence of a current hearing loss disability (i.e., one meeting the requirements of section 3.385, as noted above), and a medically sound basis for attributing such disability to service, may serve as a basis from a grant of service connection for hearing loss disability. See Hensley, 5 Vet. App. at 159. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, incurrence, or disease. The Veteran underwent an audiometer testing as a part of his entrance examination in January 1984. His results revealed his hearing was normal for VA purposes. His puretone decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 5 0 0 0 LEFT 15 10 0 0 0 The Veteran underwent an audiometer testing in October 1984. His results revealed his hearing was normal for VA purposes. His puretone decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 0 -5 -5 LEFT 10 10 -5 0 5 The Veteran underwent an audiometer testing in August 1988. His results revealed his hearing was normal for VA purposes. His puretone decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 0 -10 -10 LEFT 5 0 0 -5 0 The Veteran underwent an audiometer testing in April 1989. His results revealed his hearing was normal for VA purposes. His puretone decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 5 0 0 0 LEFT 10 0 0 0 10 The Veteran underwent an audiometer testing in his reenlistment examination in January 1989. His results revealed his hearing was normal for VA purposes. His puretone decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 0 0 0 LEFT 10 0 0 0 0 The Veteran underwent an audiometer testing in March 1990. His results revealed his hearing was normal for VA purposes. His puretone decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 0 0 0 LEFT 0 0 0 0 0 The Veteran underwent an audiometer testing as a part of his separation examination in November 1991. The Veteran denied hearing loss. His results revealed his hearing was normal for VA purposes. His puretone decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 0 5 15 0 0 LEFT 5 0 0 0 15 A November 2012 VA examination noted that a hearing loss disability was not present upon evaluation. The examination report noted a significant threshold shift of plus 15 decibels at 4000 Hz in the left ear from 1989 to 1992. The examiner noted pure tone thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 5 0 0 LEFT 10 10 10 5 15 Speech audiometry revealed speech recognition ability of 92 percent in the right ear and of 94 percent in the left ear. The Veteran reported significant noise exposure during training from gun range blasts and generators during service. The Veteran reported hearing concerns specifically in environments with conflicting noise. The Veteran reported currently working in the control booth of a steel mill with minimal noise and stated hearing protection is required. A July 2013 VA medical opinion opined that the Veteran's left ear hearing loss was less likely than not (less than a 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The examination report noted normal hearing thresholds bilaterally upon discharge on the August 1988 audiogram, and the May 1992 audiogram upon discharge. The examiner also noted hearing thresholds within normal limits on the November 2012 audiological examination. In a February 2017 VA medical opinion, the examiner opined that the Veteran's right ear hearing loss is less likely as not due to the Veteran's military service noise exposure as the Veteran's hearing was within normal limits at the time of separation with no significant worsening during his military service. The Veteran was afforded a VA examination in September 2020. The VA examiner found that the Veteran's hearing was normal. The Veteran's puretone thresholds, in decibels, and Maryland CNC results were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 10 15 15 LEFT 15 15 10 15 20 Speech audiometry revealed speech recognition ability of 64 percent in the right ear and of 64 percent in the left ear. The average decibel loss was 13.75 in the right ear and 15 in the left ear. The Veteran reported to the VA audiologist that his hearing loss makes it difficult to hear the speech of others, particularly in noisy surroundings. Following examination, the VA examiner opined that the Veteran's bilateral hearing loss is less likely than not caused by or a result of the Veteran's service. In support of this opinion, the VA examiner reasoned that the Veteran's audiogram revealed normal hearing. However, the speech recognition score is poor and is not consistent with puretone average, which is more likely to be related to a condition called "pure words deafness" or "auditory verbal agnosia." The VA examiner reported that, to his knowledge, this condition is not related to noise exposure. Therefore, the current bilateral poor speech recognition score is less likely than not caused by or a result of an event during the Veteran's military service. The Board notes that this opinion was deemed inadequate and the matter was remanded in March 2021 to determine whether the Veteran has auditory verbal agnosia and if it is due to his military service. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). In accordance with the March 2021 remand, the Veteran was afforded a VA examination in June 2021. The VA examiner reported that he could not test the Veteran's puretone thresholds or speech discrimination. The VA examiner stated that the Veteran's results are not valid for rating purposes and inconsistent with organic hearing loss. The Veteran reported to the VA audiologist that he has to ask people to repeat themselves, has difficulty hearing from a distance, uses facial cues, and has trouble with clarity. The Veteran further reported a hearing loss onset in 1992 upon discharge from active duty. Despite the lack of reliable puretones or speech discrimination scores, the VA examiner opined that the Veteran's left and right ear hearing loss are less likely than not caused by or a result of an event in military service. In support of this opinion, the VA examiner reasoned that the Veteran's January 1984 entrance examination and May 1992 separation examination both showed normal hearing. The VA examiner noted the significant shifts at 4000 and 6000 Hz in the Veteran's left ear at separation from service; however, the Veteran's left ear hearing thresholds were still within normal range and the Veteran himself denied hearing loss. The VA examiner stated that, although noise exposure is conceded, auditory damage and hearing loss are not conceded based on noise alone. Furthermore, while no reliable pure tones or speech discrimination score could not be obtained, the Veteran's admitted thresholds were not consistent with organic hearing loss. The VA examiner further reported that auditory agnosia is defined as the inability to comprehend speech. The VA examiner noted that the Veteran was able to carry on a conversation with no difficulties, even while the provider was wearing a mask. The Veteran was able to repeat several words during the speech testing, although responses were inconsistent with organic hearing loss. Thus, this would indicate that the Veteran does not have a diagnosis of auditory verbal agnosia. In considering the evidence of record under the laws and regulations above, the Board finds that the Veteran's right and left ear hearing loss is not due to an in-service injury, incurrence, or disease. Therefore, it does not warrant granting service connection. First, the audiometric test results of record during the appeal period are unclear whether the Veteran has current sensorineural hearing loss with auditory thresholds of 40 decibels or greater, or 26 decibels or greater for at least three of the frequencies 500, 1000, 2000, 3000, or 4000. 38 C.F.R. § 3.385. The November 2012 and September 2020 VA examinations show normal hearing for VA disability purposes and a January 2017 VA treatment record also shows normal hearing. The June 2021 VA examiner determined that the Veteran's puretone results are not valid for rating purposes and inconsistent with organic hearing loss. However, even if the Veteran has current left and right ear sensorineural hearing loss, there is no probative evidence of a connection (nexus) between his service and the disability. See Shedden, supra. Review of the record reveals that the Veteran's military occupational specialty (MOS) as wire systems installer. The Board notes that noise exposure has already been conceded. The Board has considered the Veteran's statements and finds him competent to report his hearing loss symptoms and exposure to noise in service. However, the determination of whether the Veteran's current hearing loss is related to in-service noise exposure is a complex medical question that requires audiological expertise. Jandreau v. Nicholson, 492 F.3d. 1372 (2007); Davidson v. Shinseki, 581 F.3d 1313, 1316. A review of the Veteran's medical records does not relate his current hearing loss to noise exposure in service. The Board gives great probative weight to the opinion of the VA examiners. The audiologists conducted thorough audiological examinations; analyzed audiometric findings; considered lay evidence; and supported the conclusion that it is reasonable to conclude that any bilateral hearing loss is less likely as not related to the Veteran's military service. Furthermore, the June 2021 VA examiner reported that the Veteran does not have a diagnosis of auditory verbal agnosia. The medical evidence also does not suggest any manifestation of bilateral hearing loss within a year of separation. As such, there is no evidence of record to warrant granting service connection for bilateral sensorineural hearing loss on a presumptive basis. 38 C.F.R. § 3.309. Thus, the Board finds the preponderance of the evidence is against the claim of entitlement to service connection for bilateral sensorineural hearing loss, and there are no doubts to be resolved. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 4. Entitlement to service connection for a right knee disability The Veteran asserts entitlement to service connection for a right knee disability. Specifically, the Veteran contends that his current right knee disability began in service, following marching and running in boots. See September 2020 VA Examination Report. The evidence establishes that the Veteran has a current right knee disability. The Veteran's June 2021 VA examination report contains a diagnosis of right knee strain. Regarding whether there was in-service event or injury, a review of the Veteran's service treatment records (STRs) shows a complaint of right knee muscle spasm in April 1992 after being hit playing basketball. X-rays showed no fracture or dislocation. The Veteran's November 1991 separation examination shows normal lower extremities and the Veteran denied experiencing swollen or painful joints, arthritis, trick or locked knee, and bone, joint, or other deformity. The Veteran was afforded a VA examination in September 2020. The VA examiner noted a diagnosis of right knee strain. The Veteran reported that his condition began in 1985 as pain in the right knee after 20-mile marches in boots and running in boots. The VA examiner reported that the Veteran's September 2020 right knee x-rays were normal. Following a physical examination, the VA examiner opined that the Veteran's right knee condition is less likely than not caused by the claimed in-service injury, event, or illness. In support of this opinion, the VA examiner merely stated that the Veteran's x-rays show no osteoarthritis. The Board notes that this opinion was deemed inadequate in the March 2021 Board remand. In accordance with the March 2021 Board remand, an addendum medical opinion was obtained in June 2021. The VA examiner opined that the Veteran's right knee strain is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of this opinion, the VA examiner reasoned that there is no evidence of a right knee condition in service and the Veteran's separation examination is negative for a right knee condition. Furthermore, the first evidence of a right knee condition isn't until 2012, when mild degenerative joint disease (DJD) was diagnosed but without x-ray evidence. The VA examiner noted that the Veteran's September 2020 x-rays are negative for DJD. Therefore, as of September 2020, the Veteran does not have a diagnosis of DJD. The VA examiner further reported that there is no right knee care proximate to service or until approximately 20 years post service. The VA examiner reasoned that it is very unlikely a condition arising in service could have gone unnoted or unreported for a span of two decades had it arisen in service. Therefore, it is less likely as not that the Veteran's right knee strain is due to or incurred in service, to include the Veteran's reports of marching, running, and physical training while wearing boots. In considering the evidence of record under the laws and regulations as set forth above, the Board finds that service connection for the Veteran's right knee strain is not warranted. The post-service evidence establishes that the Veteran has a current right knee disability. However, there is no credible evidence that he had a right knee disability during service and there is no credible evidence linking his current right knee disability to service. Although the Veteran's contends that he injured his right knee while in service, this assertion is inconsistent with the other more probative evidence of record. See Caluza, 7 Vet. App. 498, 511. The Veteran denied any right knee injuries or treatment in his STRs. The Board notes the Veteran's contentions that he injured his right knee after extended running and marching while wearing boots. However, in his separation examination, the Veteran denied experiencing any right knee symptoms and his lower extremities were normal upon evaluation. Furthermore, after reviewing the Veteran's records, the June 2021 VA examiner provided a negative nexus opinion between the Veteran's current right knee disability and his active service. The Board finds that the June 2021 VA examination and opinion offer the strongest and most probative evidence regarding the etiology of the Veteran's current right knee disability. (Continued on the next page) In summary, the evidence of record does not support that the Veteran's current right knee strain was incurred in or aggravated by active service, foreclosing the possibility of nexus between a right knee disability and active service. The preponderance of evidence is against the Veteran's claim and there is no doubt to be resolved. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). KRISTI L. GUNN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. C. Slaughter, 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.