Citation Nr: 21064594 Decision Date: 10/20/21 Archive Date: 10/20/21 DOCKET NO. 18-29 035 DATE: October 20, 2021 ORDER 1. Entitlement to service connection for migraine headaches is denied. 2. Entitlement to service connection for a left foot disability, including osteoarthritis and stress fracture, is denied. 3. Entitlement to service connection for a right knee disability is denied. 4. Entitlement to service connection for hypogammaglobinemia (CVID) is denied. 5. Entitlement to service connection for a cervical spine disability, to include arthritis, is denied. FINDINGS OF FACT 1. Migraine headaches did not have its onset in service, were not manifested within one year of service discharge, and are not otherwise related to service. 2. A left foot disability, including osteoarthritis and stress fracture, did not have its onset in service, was not manifested within one year of service discharge, and is not otherwise related to service. 3. The preponderance of the evidence is against finding that the Veteran's right knee disability was incurred in or otherwise related to service. 4. The preponderance of the evidence is against finding that CVID was incurred in or otherwise related to service. 5. A cervical spine disability did not have its onset in service, was not manifested within one year of service discharge, and is not otherwise related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for migraine headaches are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). 2. The criteria for service connection for a left foot disability, including osteoarthritis and stress fracture, are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). 3. The criteria for service connection for a right knee disability are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 4. The criteria for service connection for CVID are not met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 5. The criteria for service connection for a cervical spine disability, to include arthritis, are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from August 1983 to September 1992. The Veteran testified at a virtual hearing before the undersigned Veterans Law Judge in January 2021. In an August 2016 VA Form 21-4138, Statement in Support of Claim, the Veteran contended that she is entitled to have her case advanced on the docket because she had filed her claim as a Fully Developed Claim (FDC). In a May 2017 VA Form 21-4138 the Veteran stated due to the fact that her claim was over two years old, she was asking that her request for a hearing be expedited. In a June 2017 VA Form 21-4138, the Veteran requested to have her claim expedited due to hardship but did not provide additional detail. Appeals must be considered in docket number order but may be advanced if sufficient cause is shown. See 38 U.S.C. § 7107(a)(2); 38 C.F.R. § 20.900(c). Sufficient cause includes advanced age (defined as 75 years or more), serious illness, severe financial hardship, or administrative error resulting in a significant delay. An appeal may also be advanced if the case involves interpretation of a question of law of widespread application affecting other claims, although this is extremely rare. Any motion for advancement should be supported by pertinent documentation. The Board has considered the Veteran's request to have her case advanced on the docket (AOD) but finds that she has not submitted sufficient evidence to demonstrate the necessity of an AOD due to any of the reasons listed. Thus, sufficient cause to grant an AOD is not shown, and the request is denied. In the May 2018 rating decision, the Veteran's claim for entitlement to service connection for migraine headaches was denied because the evidence submitted was not new and material. The May 2018 rating decision stated that the Veteran had not submitted a Notice of Disagreement (NOD) to the October 2016 rating decision denying service connection for migraine headaches. However, in a June 2018 VA Form 21-4138, the Veteran contended that she had submitted a timely NOD. The Veteran provided a copy of a submission of a May 2017 NOD for migraine headaches, including a fax cover page from the State of Illinois Department of Veterans' Affairs with a timestamp from May 2017 showing that she had submitted a timely disagreement. The Board finds that the Veteran submitted a timely NOD to the October 2016 rating decision denying service connection for migraine headaches, and the October 2016 rating decision is not final. Accordingly, the claim shall be construed as entitlement to service connection for migraine headaches, and an analysis as to whether new and material evidence was submitted is not warranted. As the agency of original jurisdiction considered the Veteran's claim for service connection for migraine headaches on the merits within the July 2018 statement of the case, the Veteran is not prejudiced by the Board's consideration of the claim on the merits. In the December 2015 Notice of Disagreement (NOD), the Veteran contended that many of her STRs were lost after service. At the January 2021 Board hearing the Veteran stated that many of her STRs were missing and could not be located. The Veteran stated that she had sought the assistance of Congresswoman Bustos to help retrieve the records, but the records could not be found. In a VA 21-3101, VA stated that the records referenced by the Veteran could not be located. The Board has a heightened duty to assist and explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule where service records are missing or presumed destroyed. The threshold for allowance of a claim is not lowered; and there is no presumption, either in favor of or against the claimant. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). 1. Entitlement to service connection for migraine headaches At the January 2021 Board hearing, the Veteran testified that her migraine headaches were the result of the neck injury that resulted in her cervical spine disability in service. The Veteran stated that she regularly sought treatment for migraine headaches during service. The Veteran stated that she sought care in the emergency room for migraine headaches while stationed at Upper Hayford; Randolph Air Force Base in Texas; and Fort Sam Houston. The Veteran contended that a VA physician attributed her migraine headaches to her cervical spine injury during service. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of service connection for migraine headaches on a direct or presumptive basis. The reasons follow. The Veteran has been diagnosed with migraine headaches, and thus there is evidence of a current disability. For example, an August 1997 private treatment record shows the Veteran visited the Burlington Medical Center emergency room complaining of migraine headaches. Thus, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, the evidence does not support a finding of a disease or injury in service indicative of migraine headaches. The Veteran has claimed that the headaches were associated with the cervical spine/neck pain she experienced in service, which cervical spine/neck pain is documented in the service treatment records (STRs). However, the STRs showing complaints of neck pain do not also document headaches, and many of the STRs included detailed descriptions of the symptoms the Veteran was experiencing at that time, which did not include a report of headaches. For example, on August 27, 1985, the Veteran was admitted to the hospital for a tonsillectomy. She complained of neck pain. She reported having strained her neck at a carnival on July 4, 1985. The August 1985 record shows the Veteran reported she had awoken that morning with pain on the right side of her neck and was unable to straighten her head. She described the pain as constant and sharp. On August 28, 1985, the Veteran complained of neck pain. The examiner documented that the Veteran was now having pain in the right side of the cervical area. The examiner then documented clinical findings, which did not include headaches. In June 1987, when the Veteran was admitted for partial obstruction of the left submandibular gland and dental impactions and complained of neck pain, the hospital records do not document the Veteran reporting headaches. When her past medical history was discussed at that time, headaches were not included. The examiner noted that the Veteran denied "significant adult illness other than chronic sinus problems." An August 1991 record shows that the Veteran specifically denied headaches at that time. A physical examination was performed, and the "head and neck" were found to be normal. In an April 1992 STR, it shows that a review of the neurological system was performed, and the Veteran denied headaches at that time. While some STRs are missing, of record are 300 pages of service treatment records, which do not include complaints of headaches, but include multiple other medical symptoms the Veteran experienced during service with some records documenting a denial of headaches at that time. This is not a situation where there is silence in the service treatment records of whether the Veteran was experiencing headaches but rather where on numerous occasions, she denied headaches. The Veteran's allegations of having been treated for headaches during service is not supported by the contemporaneous records. This finding is further supported by the post service medical records. For example, when seen in August 1993 for right knee pain, when asked about her past medical history, the Veteran reported tonsillectomy and a laparoscopic evaluation for her menstrual problems. Headaches were not included in her medical history. Then when she was seen in July 1994 for left foot pain, when addressing her past medical history, the examiner wrote, "Patient denies systemic disease except for history of stomach ulcers." In 1994, it had been almost two years since service discharge, and the Veteran was not reporting a medical history involving headaches. She states that the headaches began in approximately 1984. At this point, according to the Veteran, she would have been experiencing headaches for approximately 10 years. The fact that she denied "systemic disease" at that time except for stomach ulcers leads the Board to conclude that she was not having chronic headaches in service or in the two years since service; otherwise, she would have reported that fact when treated in either 1993 or 1994, while she reported her past medical history and specifically reported other medical symptoms she had experienced. Accordingly, for all these reasons, the Board finds the preponderance of the evidence is against a finding of complaints or symptoms related to migraine headaches during service, and the in-service disease or injury element is not met. Stated differently, the Veteran's allegations of experiencing headaches throughout her period of active service are found not credible. The preponderance of the evidence is also against a nexus between migraine headaches and service. For example, the Veteran visited a private treatment facility in August 1997 complaining of migraine headaches for one week. In February 1998, the Veteran was diagnosed with acute cephalgia and acute migraine cephalgia with muscle tension headache. During treatment visits in February 1998, the Veteran reported experiencing low grade headaches daily for the past couple of weeks. In a May 2018 Disability and Benefits Questionnaire, the Veteran's private examiner, Dr. Dan M. Cox, wrote that the Veteran's migraine headaches were diagnosed in June 2014. The timeline of symptoms is, at the earliest, approximately five years following service discharge and does not support that migraine headaches had their onset in service. In a June 2018 VA Form 21-4138, the Veteran contended that the fact that she reported a history of migraine headaches in a February 1998 private treatment record proves that she suffered from migraine headaches during service and fulfills the nexus requirement for service connection. However, the Board notes that the Veteran was originally seen in August 1997 for migraine headaches, so the mention of previous migraine headaches in February 1998 does not prove that the Veteran experienced migraine headaches during service. Again, when the Veteran sought treatment for headaches in 1997, she had reported a recent onset of headache painnot longstanding headache pain. Accordingly, the Veteran's contention is outweighed by the contemporaneous records. As to presumptive service connection for a chronic disease, the Board finds that the Veteran did not incur an event, injury, or disease related to her current migraine headaches in service and that her migraine headaches did not manifest during service or within one year of separation from service. As noted above, the Veteran did not report a past medical history of headaches in 1993 and 1994, which is evidence against headaches manifesting within one year of service discharge. Furthermore, the evidence of record does not demonstrate that the Veteran's symptoms have been continuous since separation from service. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). There were no complaints, diagnosis, or treatment for this disorder for approximately five years following service discharge until the Veteran was sought treatment for migraine headaches in August 1997. The absence of post-service complaints, findings, diagnosis, or treatment for approximately five years after service is one factor that tends to weigh against a finding of continuous symptoms since separation from service. The Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence. A prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. While the Veteran alleges that the migraine headaches are related to service, to include the in-service neck pain she experienced, she is not competent to attribute the migraine headaches to service, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's opinion is nonprobative evidence. At the present time, there is no competent evidence of a nexus between the migraine headaches and service, and the nexus element of a service-connection claim is not met. VA did not provide the Veteran with a VA examination in connection with this claim. VA must provide a medical examination and/or medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, for the reasons described above, the Board finds both that there was not an event, injury, or disease that occurred in service, or that migraine headaches manifested during the one-year period following service discharge. The evidence also does not establish migraine headaches may be associated with the Veteran's service. For a VA examination and/or medical opinion to be warranted, all the McLendon criteria have to be met, and at least one of the criteria is not met. Therefore, entitlement to a VA examination and/or medical opinion is not warranted for this claim. In sum, for all the reasons laid out above, the Board concludes that the preponderance of the evidence of record is against the Veteran's claim for service connection for migraine headaches. The benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107(b) is not applicable, as there is no approximate balance of evidence. 2. Entitlement to service connection for a left foot disability, including osteoarthritis and stress fracture. At the January 2021 Board hearing, the Veteran contended that she injured her left foot during basic training in San Antonio at Lackland Air Force Base and was diagnosed with a stress fracture. The Veteran contended that she feared being removed from service for seeking treatment related to this injury. The Veteran stated she took Tylenol but continued to engage in the exercises necessary for basic training, including going on runs and marching. The Veteran stated she was told by her podiatrist that her stress fracture was due to overuse. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of service connection for a left foot disability, including osteoarthritis and stress fracture on a direct or presumptive basis. The reasons follow. The Veteran has been diagnosed with a left foot disability, and thus there is evidence of a current disability. For example, a June 2018 VA treatment record shows the Veteran was diagnosed with mild osteoarthritis of the left foot. Thus, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, the evidence does not support a finding of a disease or injury in service indicative of a left foot disability. For example, in a July 1986 service record, the Veteran's extremities were found to be within normal limits. A January 1989 STR shows that the Veteran's extremities had no edema and full range of motion. A separate January 1989 STR shows that the Veteran was undergoing nasal surgery and when asked if she had any other health problems, the response was, "No." When a review of systems was performed, under the "Musculoskeletal" system, the examiner wrote, "P[atien]t denies." In an August 1991 record, the examiner noted that the Veteran had no history of musculoskeletal issues. In another August 1991 record, the Veteran denied having any physical disabilities. When undergoing her laparoscopy in April 1992, a systems review was performed. When addressing the musculoskeletal system, which included deformities, pain, stiffness, contractures, history of fractures, and joint replacement, the examiner wrote, "P[atien]t denies." All of these facts weigh against a finding that the Veteran experienced a left foot disease or injury during service, including a stress fracture. While some STRs are missing, of record are 300 pages of service treatment records, which do not include complaints of left foot symptoms, to include a stress fracture, but include multiple other medical symptoms the Veteran experienced during service with some records documenting a denial of musculoskeletal symptoms at that time. This is not a situation where there is silence in the service treatment records of whether the Veteran was experiencing left foot symptoms but rather where on numerous occasions, she denied musculoskeletal symptoms. The Veteran's allegations of having been treated for a left foot stress fracture during service is not supported by the contemporaneous records. Accordingly, the preponderance of the evidence is against a finding of complaints or symptoms related to a left foot disease or injury during service, and the preponderance of the evidence is against an in-service disease or injury, and the second element of a service-connection claim is not met. Stated differently, the Veteran's allegations of experiencing a stress fracture to her left foot during service are found not credible. The preponderance of the evidence is also against a nexus between the current left foot disability and service. For example, a January 1993 private treatment record shows that the Veteran was seen for a knot on her left foot. She reported that she had been experiencing pain in her left foot for "about the last two weeks." The Veteran denied a history of gout or any other arthritis problems. This treatment record shows a recent onset of left foot pain. Additionally, if the Veteran had experienced a stress fracture during service, to include ongoing left foot pain, it would seem likely that she would have reported that fact at the time of the January 1993 treatment, as it would have been relevant to the symptoms she was experiencing at that time. A left foot x-ray at that time showed, "Intact bones." Additionally, in a March 9, 1994 private treatment record, the Veteran stated that she had ongoing left foot pain for the past nine months. These facts show that the Veteran experienced left foot symptoms after service discharge. In a March 19, 1994 private treatment record, the Veteran reported she again injured her foot in a fall two days ago. In July 1994, the Veteran attributed her recent injury to hitting a large table. These treatment records establishes that the Veteran's left foot disability had its onset after service. In a December 2015 VA treatment record, the Veteran stated that she first injured her foot in a motorcycle accident 25 years ago, which would have been in approximately 1990. In a March 2015 VA Form 21-4138, the Veteran stated that she originally received treatment for her feet during service in either August or September of 1983. As these statements are inconsistent with one another, and are not supported by the record, the Board affords these statements no probative value, and finds that the Veteran's overall credibility has been negatively impacted. As to presumptive service connection for a chronic disease, the Board finds that the Veteran did not incur an injury or disease related to her left foot in service and that her left foot disability did not manifest during service or within one year of separation from service. An x-ray performed less than one year following service discharge shows that the bones in her left foot were intact. Osteoarthritis was first diagnosed in June 2018. This is evidence against osteoarthritis manifesting within one year of service discharge. VA did not provide the Veteran with a VA examination in connection with this claim. The Board has laid out the requirements for entitlement to a VA examination and/or medical opinion above. Here, as explained above, the Board finds that the evidence does not establish that an event, injury, or disease occurred in service, or that a left foot disability may be associated with the Veteran's service. For a VA examination and/or medical opinion to be warranted, all the McLendon criteria have to be met, and at least one of the criteria is not met. Therefore, entitlement to a VA examination and/or medical opinion is not warranted for this claim. In sum, for all the reasons laid out above, the Board concludes that the preponderance of the evidence of record is against the Veteran's claim for service connection for a left foot disability, including osteoarthritis and stress fracture. The benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107(b) is not applicable, as there is no approximate balance of evidence. 3. Entitlement to service connection for a right knee disability At the January 2021 Board hearing, the Veteran testified that while she was stationed in the United Kingdom during service, she fell while wearing her chemical warfare gear, boots, and she "hyperflexed" her knee. The Veteran said she was given an ice pack to treat the injury during that particular exercise, but later sought medical treatment when she returned to her regular base. She stated she was later given pain medication and a brace, and that her in-service treatment providers managed the issue as an acute problem. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of service connection for a right knee disability. The reasons follow. The Veteran has been diagnosed with a right knee disability, and thus there is evidence of a current disability. For example, the Veteran was diagnosed with right knee arthralgia in a June 2012 VA treatment record. Thus, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, the evidence does not support a finding of a disease or injury in service indicative of a right knee disability. For example, in a July 1986 STR, the Veteran's extremities were found to be within normal limits. A January 1989 STR shows that the Veteran's extremities had no edema and full range of motion. A separate January 1989 STR shows that the Veteran was undergoing nasal surgery and when asked if she had any other health problems, the response was, "No." When a review of systems was performed, under the "Musculoskeletal" system, the examiner wrote, "P[atien]t denies." In an August 1991 record, the examiner noted that the Veteran had no history of musculoskeletal issues. In another August 1991 record, the Veteran denied having any physical disabilities. When undergoing her laparoscopy in April 1992, a systems review was performed. When addressing the musculoskeletal system, which included deformities, pain, stiffness, contractures, history of fractures, and joint replacement, the examiner wrote, "P[atien]t denies." All of these facts weigh against a finding that the Veteran experienced a right knee disease or injury during service. In the August 2018 VA Form 9, the Veteran contended that she received treatment for her right knee disability during service. However, this contention is not supported by the record. While some STRs are missing, of record are 300 pages of service treatment records, which do not include complaints of right knee symptoms, but include multiple other medical symptoms the Veteran experienced during service with some records documenting a denial of musculoskeletal symptoms at that time. This is not a situation where there is silence in the service treatment records of whether the Veteran was experiencing right knee symptoms but rather where on numerous occasions, she denied musculoskeletal symptoms. Accordingly, the preponderance of the evidence is against a finding of complaints or symptoms related to a right knee disability during service, and the in-service disease or injury element is not met. Stated differently, the Veteran's allegations of experiencing a right knee injury during service are found not credible. The preponderance of the evidence is also against a nexus between the current right knee disability and service. For example, an August 1993 private treatment record shows that the Veteran reported she had twisted her knee on July 30, 1993, which shows the Veteran reporting the onset of right knee pain as a result of a post-service injury. A separate August 1993 record documents the injury in more detail. The examiner wrote, "The p[atien]t was at work on Friday and slipped on some water on the floor and twisted her right knee." Under past history, the examiner wrote, "No past trauma." The denial of past trauma further supports the finding that the Veteran did not experience a disease or injury involving her right knee in service. As she specifically attributed her knee symptoms at that time to a post-service, work-related injury that occurred in July 1993, this is evidence against a nexus between the post-service right knee disability and service. In a March 7, 2001 private treatment record from the Great Medical Center, the Veteran reported that she had injured her right knee in December 2000. In a March 9, 2001 private treatment record, the Veteran was diagnosed with right knee pain, possible synovial plica, possible meniscus tear and she reported that she had fallen and twisted her knee. This post-service evidence shows a second post-service injury to her right knee, which is further evidence against a finding that the right knee disability had its onset in service. In a June 2012 VA treatment record, the Veteran was diagnosed with right knee arthralgia, and it was noted that she had previously undergone a knee arthroscopy. Despite numerous injuries and related treatments beginning in 1993 and continuing at least through 2018, the Veteran did not attribute her right knee disability and/or symptoms to service, and, instead specifically, attributed her injuries to incidents after service. When seen in August 1993, she specifically denied past trauma. All of this evidence is against a finding that the right knee disability had its onset in service. VA did not provide the Veteran with a VA examination in connection with this claim. The Board has laid out the requirements for entitlement to a VA examination and/or medical opinion above. Here, as explained above, the Board finds that the evidence does not establish that an event, injury, or disease occurred in service, or that a right knee disability may be associated with the Veteran's service. For a VA examination and/or medical opinion to be warranted, all the McLendon criteria have to be met, and at least one of the criteria is not met. Therefore, entitlement to a VA examination and/or medical opinion is not warranted for this claim. In sum, for all the reasons laid out above, the Board concludes that the preponderance of the evidence of record is against the Veteran's claim for service connection for a right knee disability. The benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107(b) is not applicable, as there is no approximate balance of evidence. 4. Entitlement to service connection for CVID At the January 2021 Board hearing, the Veteran testified that she was initially diagnosed with a gamma globulin problem in 1990 or 1991 during service. The Veteran contended that her gamma globulin problem was a predictor of her later diagnosis of CVID. The Veteran also contended that her sinus, gastrointestinal, and gynecological issues recorded during service were unrecognized symptoms of CVID. The Veteran also separately contended that she was diagnosed with CVID during service. The Veteran contended that the July 2018 VA opinion was inadequate because it was not rendered by an immunologist. Initially, the Board notes that Common variable immune deficiency (CVID) is a disorder that impairs the immune system. See https://medlineplus.gov/genetics/condition/common-variable-immune-deficiency/. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of service connection for CVID. The reasons follow. The Veteran has been diagnosed with CVID, and thus there is evidence of a current disability. For example, the July 2018 VA examination noted that the Veteran was diagnosed with combined variable immunodeficiency in December 2014. Thus, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, the evidence supports a finding of a disease or injury in service indicative of CVID. For example, with respect to the above mentioned contentions at the January 2021 Board hearing, the evidence support that the Veteran was diagnosed pelvic inflammatory disease and chlamydia during service and was treated for sinus problems. For example, an August 1991 STR shows the Veteran was diagnosed with chlamydia. Additional records from August 1991 show that the Veteran was treated for pelvic inflammatory disease (PID). In January 1989, the Veteran complained of left sided sinus trouble and discussed a history of multiple sinus infections in the axillary and frontal regions, noting that the left side was much worse than the right. As sinus infections are a known symptom of CVID, the Board finds that the in-service disease or injury element is met. However, the Board finds the preponderance of the evidence is against a nexus between the post-service diagnosis of CVID and service. For example, the Veteran was first diagnosed with CVID in December 2014, which is approximately 22 years following service discharge, and does not lend to a finding that CVID had its onset in service. Additionally, in a July 2018 VA examination report, the examiner opined that that the Veteran's CVID was less likely than not related to or otherwise incurred in service, explaining that the Veteran was diagnosed with CVID many years after separation from service. The examiner explained that there is no evidence that the Veteran was seen by any hematologist or an immunologist in the service, and no diagnosis was made during service. The examiner noted the Veteran's medical history during service and discussed the history of the Veteran's upper respiratory infections, sinus infections, gynecological problems, such as pelvic inflammatory disease, and a nasal bone fracture due to a softball injury during service. The examiner also recorded that the Veteran underwent a septoplasty and laparoscopic surgery to exclude any endometriosis. The VA examiner opined that in light of the Veteran's medical history, her in-service complaints of sinus problems do not support that her CVID is related to service. In light of the VA examiner's thorough review of the Veteran's STRs and her medical history and the rationale for why he found it less likely than not that CVID was related to service, this opinion establishes that CVID did not have its onset in service and is not otherwise related to service. With regard to the Veteran's contention that the July 2018 VA opinion is inadequate because it was not issued by an immunologist, in the case of competent medical evidence, VA benefits from a presumption that it has properly chosen a person who is qualified to provide a medical opinion in a particular case. It is presumed that VA followed a regular process that ordinarily results in the selection of a competent medical professional. Viewed correctly, the presumption of competence is not about the person or a job title; it is about the process. Further, the provisions of 38 C.F.R. § 3.159(a)(1) state that competent medical evidence is evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements, or opinions. Here the examiner held the degree of Medical Doctor. Accordingly, the Board finds that the examiner was qualified through education, training or experience to offer medical diagnoses, statements, or opinions. The Veteran submitted an article in support of the claim. The article provides a brief description of CVID and generally discussed the etiology of the disability in the populace. Medical treatise evidence can, in some circumstances constitute competent medical evidence. Competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses. However, the U.S. Court of Appeals for Veterans Claims has held that medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. Here, the article submitted by the appellant is general in nature and does not specifically relate to the facts and circumstances surrounding the Veteran's particular case. For example, this article does not address a relationship between the Veteran's in-service symptoms and CVID. Thus, this article is not the equivalent of a statement from a medical expert who actually reviewed the Veteran's medical history and rendered a definitive opinion based on the specifics of the Veteran's history. At the January 2021 Board hearing, the Veteran contended that her symptoms of gastrointestinal issues and gynecological problems during service represented symptoms of CVID. The Veteran also contends that she suffered from chlamydia, due to a military sexual trauma during service, which caused her CVID. Although the Veteran claims that the CVID is related to service, she is not competent to directly link the CVID to service, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's opinion is nonprobative evidence. At the present time, there is no competent evidence of a nexus between the CVID and service to weigh against the July 2018 VA opinion, and the nexus element of a service-connection claim is not met. In May 2017, the Veteran submitted a statement from with co-worker who wrote about the negative impact the Veteran's CVID had on her ability to work. A separate statement documents that this person has worked alongside with the Veteran and has "become familiar with [the Veteran]'s illness and its negative effect on her ability to execute her duties. The issue of whether such disability exists is not in dispute. These statements do not provide competent evidence of a nexus between the current diagnosis of CVID and service. Without evidence of a nexus between the current diagnosis of CVID and service, service connection for such disability is not warranted. In sum, for all the reasons laid out above, the Board concludes that the preponderance of the evidence of record is against the Veteran's claim for service connection for CVID. The benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107(b) is not applicable, as there is no approximate balance of evidence. 5. Entitlement to service connection for a cervical spine disability At the January 2021 Board hearing the Veteran testified she was admitted to the hospital during service with cervical spine issues, and then was required to wear a neck collar and undergo physical therapy. The Veteran stated that the night prior to her hospital admission, she had attended a carnival and participated in rides. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the award of service connection for a cervical spine disability on a direct or presumptive basis. The reasons follow. The Veteran has been diagnosed with a cervical spine disability, and thus there is evidence of a current disability. For example, the Veteran was diagnosed with degenerative arthritis of the spine in June 2016. Thus, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, the evidence supports a finding of a disease or injury in service indicative of a cervical spine disability. The STRs show that the Veteran sought treatment in August 1985 after a neck injury at a carnival in July 1985. The Veteran wore a neck collar for two days, but experienced neck pain on the right side and could not straighten her head. The Veteran underwent cervical spine x-rays and complained that she fainted when the technician straightened her head. The Veteran was diagnosed with torticollis in relation to this incident. In an August 1985 "Patient Problem List," the Veteran was noted to have cervical strain. In June 1987 the Veteran complained of left neck swells at every meal for the past six weeks and separately complained of pain in her left neck that was unresponsive to Tylenol. The Veteran stated that this issue began in early May 1987. In light of the foregoing, the Board finds that in-service disease or injury element of a service-connection claim is met. However, the Board finds the preponderance of the evidence is against a nexus between a cervical spine disability and service. For example, a January 1989 STR shows that a physical examination was completed at that time, and the Veteran's neck examination was normal. In another January 1989 record, the Veteran denied experiencing any other health problems. An August 1991 service treatment record shows that a systems review was performed at that time, and the musculoskeletal system was documented as being negative for symptoms. When undergoing her laparoscopy in April 1992, a systems review was performed. When addressing the musculoskeletal system, which included deformities, pain, stiffness, contractures, history of fractures, and joint replacement, the examiner wrote, "P[atien]t denies." Thus, following the in-service neck injury in July 1985 and subsequent pain in 1985 and 1987, the Veteran did not continue to experience cervical spine pain while still in service. This is evidence against continuity of symptoms. In a February 1998 private treatment record from the Emergency Room at Burlington Medical Center, the Veteran denied neck pain and was found to have a normal range of motion in her neck. At this point, it had been more than five years following service discharge and more than 10 years following the in-service cervical spine/neck pain, and the Veteran was denying neck pain, which is further evidence against continuity of symptoms. A July 2012 VA treatment record shows the Veteran's neck was examined but no abnormal results were found. In a February 2015 VA treatment record, the Veteran was seen for puffiness in her supraclavicular area with intermittent cervical and axillary tender adenopathy, which was documented to be most often associated with a sore throat. The record does not support complaints or findings related to the Veteran's cervical spine disability. The Veteran was first diagnosed with a cervical spine disability in June 2016 according to the February 2017 VA examination, which is approximately 24 years following service discharge, and also tends to establish that a cervical spine disability did not have its onset in service. Additionally, in a March 2017 VA medical opinion, the examiner documented the Veteran reported that she suffered an injury after lifting boxes and attending a recreational ride during service. The March 2017 VA examiner opined that the Veteran's cervical spine disability was less likely than not incurred in otherwise related to service, explaining that degenerative changes over the course of several years are not likely to have been caused by a single episode of cervical strain or torticollis. The Board finds this opinion to be probative, as the examiner provided a well-reasoned rationale that discussed the Veteran's contention that her original in-service injury had caused her current disability, the progression of the Veteran's disability over time, and an analysis of the likely etiology of the Veteran's current disability. This opinion establishes that a cervical spine disability is not related to service. As to presumptive service connection for a chronic disease of arthritis, the Board finds that the Veteran's symptoms have been continuous since separation from service. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). There were no complaints, diagnosis, or treatment for this disability for approximately 24 years following service discharge until the Veteran was diagnosed with a cervical spine disability in June 2016. The absence of post-service complaints, findings, diagnosis, or treatment for approximately 24 years after service is one factor that tends to weigh against a finding of continuous symptoms since separation from service. The Board may weigh the absence of contemporaneous medical evidence as one factor in determining credibility of lay evidence. A prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability. Although the Veteran claims that her cervical spine disability is related to the injury she sustained in service in 1985, she is not competent to provide a nexus between the cervical spine disability and service, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's opinion is nonprobative evidence. At the present time, there is no competent evidence of a nexus between a cervical spine disability and service to weigh against the March 2017 VA negative nexus opinion, and the nexus element of a service-connection claim is not met. In sum, for all the reasons laid out above, the Board concludes that the preponderance of the evidence of record is against the Veteran's claim for service connection for a cervical spine disability, to include arthritis. The benefit-of-the-doubt doctrine enunciated in 38 U.S.C. § 5107(b) is not applicable, as there is no approximate balance of evidence. A. P. SIMPSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Husain, 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.