Citation Nr: 21069506 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 19-00 491 DATE: November 18, 2021 ORDER An initial disability rating in excess of 50 percent for posttraumatic-stress disorder (PTSD) is denied. New and material evidence having been received, the application to reopen a previously denied claim of entitlement to service connection for sleep apnea, formerly claimed as a sleep condition, is granted and the claim is reopened. New and material evidence having been received, the application to reopen a previously denied claim of entitlement to service connection for gout, to include as secondary to a right knee disability, is granted and the claim is reopened. Entitlement to service connection for sleep apnea is denied. Entitlement to service connection for gout, to include as secondary to a right knee disability is denied. FINDINGS OF FACT 1. The Veteran's acquired psychiatric disability was manifested by occupational and social impairment with reduced reliability and productivity; there is no showing of occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. 2. In an August 2006 rating decision, the claim of entitlement to service connection for a sleep condition was denied on the ground that it did not occur in and was not caused by the Veteran's active duty service. 3. In a June 2015 rating decision, the claim of entitlement to service connection for gout, to include as secondary to a right knee disability, on the ground that the evidence failed to show that the Veteran's gout resulted from or was aggravated by his service-connected right knee disability or that he had gout during active duty service. 4. The evidence added to the record since the August 2006 and June 2015 rating decisions relates to unestablished facts that are necessary to substantiate the claims of entitlement to service connection for sleep apnea and gout. 5. The preponderance of the evidence of record is against finding that the Veteran has, or has had at any time during the appeal, a current diagnosis of sleep apnea. 6. The Veteran's gout was not shown in service or for many years thereafter and is not otherwise etiologically related to his active duty service, including his service-connected right knee disability. CONCLUSIONS OF LAW 1. The criteria for an initial disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.7, 4.130, Diagnostic Code (DC) 9411. 2. The August 2006 rating decision that denied the Veteran's claim of entitlement to service connection for sleep apnea, formerly claimed as a sleep condition, is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 3. Because the evidence received after the August 2006 rating decision is new and material, the requirements to reopen the Veteran's claim of entitlement to service connection for sleep apnea, formerly claimed as a sleep condition, have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.102, 3.156. 4. The June 2015 rating decision that denied the Veteran's claim of entitlement to service connection for gout, to include as secondary to a right knee disability, is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 5. Because the evidence received after the June 2015 rating decision is new and material, the requirements to reopen the Veteran's claim of entitlement to service connection for gout, to include as secondary to a right knee disability, have been met. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. §§ 3.102, 3.156. 6. The criteria for service connection for sleep apnea have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a), 3.304, 3.307, 3.309. 7. The criteria for service connection for gout, to include as secondary to the Veteran's service-connected right knee disability, have not been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 2000 to December 2004. In June 2021, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. Increased Ratings Disability evaluations are determined by the application of a schedule of ratings that is based on average impairment of earning capacity. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. See 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities. Although the Board typically considers only those factors contained wholly in the rating criteria, it is proper to consider factors outside the specific rating criteria when appropriate to best determine the level of occupational and social impairment. See Mauerhan v. Principi, 16 Vet. App. 436 (2002); Massey v. Brown, 7 Vet. App. 204, 208 (1994). Where there is a question as to which of two separate evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that particular rating. 38 C.F.R. § 4.7. When a reasonable doubt arises regarding the degree of disability, such doubt will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. 1. Entitlement to an initial disability rating in excess of 50 percent for PTSD The Veteran's acquired psychiatric disability has been assigned an initial 50 percent disability rating under 38 C.F.R. § 4.130, DC 9411. He is seeking an initial disability rating in excess of 50 percent, asserting that his symptoms include irritability, impaired impulse control, interacting with other people, particularly in an occupational setting, isolating behavior, and daily passive suicidal thoughts, show that his occupational and social impairment is more significant than the 50 percent disability rating currently assigned to his PTSD. In order to warrant a 70 percent disability rating, the evidence must show occupational and social impairment, with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood, resulting in an inability to establish and maintain effective relationships, characterized by symptoms including, but not limited to suicidal ideation; obsessional rituals that interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; and difficulty in adapting to stressful circumstances (including work or a worklike setting). 38 C.F.R. § 4.130, DC 9411. After a review of the evidence of record, the Board concludes that an initial disability rating in excess of 50 percent for the Veteran's acquired psychiatric disability is not warranted. Initially, the reports from the February 2014 and June 2019 VA examinations fail to show that a disability rating in excess of 50 percent is warranted because they do not show that the Veteran's PTSD has been manifested by occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. First, the report from the February 2014 VA examination fails to show that the Veteran's PTSD has caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. The examination report reflects that the examiner determined that the Veteran's acquired psychiatric disability manifested itself through symptoms of depressed mood, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, and disturbances of motivation and mood. The examination report also reflects that the Veteran indicated that he became irritable almost every day, experienced constant mood swings, was "very impatient," had recurring nightmares, had difficulty with schoolwork due to a lack of concentration or focus "at times," and was hypervigilant when he heard loud noises. Additionally, the examination report reflects that at the time of the examination, he was employed as a manager at a pizza chain, had a bachelor's degree and was working on a master's degree in accounting. Based upon an in-person examination and a review of the claims file, the examiner opined that a mental condition had been formally diagnosed, but that symptoms were not severe enough either to interfere with occupational and social functioning or to require continuous medication, the level of occupational and social impairment that warrants a noncompensable disability rating. The report from the June 2019 VA examination also fails to show that the Veteran's PTSD has caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. The examination report reflects that the examiner determined that the Veteran's acquired psychiatric disability manifested itself through symptoms of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, impairment of short and long term memory, for example, retention of only highly learned material, while forgetting to complete tasks, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. Additionally, the examination report reflects that he arrived 10 minutes early to the evaluation, was oriented to person, place, time, and situation, was clean and casually dressed in clothing that was appropriate for the season, was relaxed and cooperated, exhibited a normal mood, exhibited a congruent affect, denied active suicidal and homicidal ideation, denied psychotic symptoms and delusional processes, did not seem to be responding to internal stimuli, and understood all questions asked. Further, the examination report reflects that he indicated that he sometimes became startled, particularly around fireworks, became irritable "very quickly," was concerned about his anger, and became distracted easily, resulting in him not completing tasks. Based upon an in-person examination and a review of the claims file, the examiner opined that his PTSD caused occupational and social impairment with reduced reliability and productivity, the level of occupational and social impairment that warrants the assignment of a 50 percent disability rating. In light of these clinical evaluations, the Board finds that the Veteran does not exhibit objective symptomatology sufficient to warrant a rating in excess of 50 percent. Here, the symptoms observed by the February 2014 VA examiner are symptoms indicative of occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. The symptoms observed by the June 2019 VA examiner are also symptoms indicative of depressed mood, anxiety, suspiciousness, chronic sleep impairment, mild memory loss, such as forgetting names, directions, or recent events, impairment of occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks. Importantly, neither VA examiner observed symptoms representative of occupational and social impairment with deficiencies in most areas, including, without limitation, suicidal ideation, obsessional rituals that interfere with routine activities, speech intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately and effectively, impaired impulse control, spatial disorientation, neglect of personal appearance and hygiene, difficulty in adapting ot stressful circumstances, and an inability to establish and maintain effective relationships. Importantly, in contrast with those symptoms that are identified as indicative of occupational and social impairment with deficiencies in most areas, the June 2019 VA examiner observed that the Veteran denied active suicidal and homicidal ideation, denied psychotic symptoms and delusional processes, understood all questions asked, was oriented to person, place, time, and situation, was clean and casually dressed in clothing that was appropriate for the season, was relaxed and cooperated, exhibited a normal mood and congruent affect, and understood all questions asked. Accordingly, the Board concludes that the reports from the February 2014 and June 2019 VA examinations fail to show that an initial disability rating in excess of 50 percent is warranted for the Veteran's PTSD. Nevertheless, VA must engage in a holistic analysis in which it assesses the severity, frequency, and duration of the signs and symptoms of the veteran's service-connected mental disorder; quantifies the level of occupational and social impairment caused by those signs and symptoms; and assigns an evaluation that most nearly approximates that level of occupational and social impairment. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 115-17 (Fed. Cir. 2013). Here, the Board acknowledges that the report from the June 2019 VA examination reflects that the Veteran reported that he became irritable very quickly, which could be demonstrative of occupational and social impairment with deficiencies in most areas. The Board also acknowledges that a June 2016 private treatment record reflects that he had passive thoughts of suicide and that he testified that he continues to have passive thoughts of suicide, which is also a symptom indicative of occupational and social impairment with deficiencies in most areas. Further the Board acknowledges that the report from the June 2019 VA examination reflects that he was unemployed at the time of the examination and that he testified that his PTSD made it difficult for him to maintain a job, which could be indicative of a difficulty in adapting to stressful circumstances, and that a March 2018 private treatment record reflects that his PTSD affected his productivity at work. Although the Veteran reports that he experiences these symptoms, the Board finds that these reported symptoms are not sufficient to establish that an initial disability rating in excess of 50 percent is warranted for the Veteran's PTSD. With respect to irritability, the clinical evidence fails to show that his irritability is frequent, severe or of a significant duration such that his irritability would warrant an increased disability rating. Indeed, the clinical evidence does not show that his irritability has resulted in unprovoked periods of violence, and treatment records, including April 2015 and June 2018 treatment records reflect that his behavior was cooperative, and his mood was normal or good, weighing against finding that his irritability was frequent, severe, or lasted for significant durations. With respect to his reported passive thoughts of suicide, numerous treatment records, including February 2015, May 2016, August 2017, October 2017, December 2017, June 2018 treatment records reflect that he denied suicidal ideation, showing that the reported passive thoughts of suicide were not of a frequency, severity, or duration such that the assignment of a 70 percent disability rating is warranted. With respect to his reported difficulties with maintaining a job, the Board notes that the evidence shows that when the February 2014 VA examination was conducted, he had worked for two years as a manager at a pizza chain and that he was working on his bachelor's degree, and that the report from the June 2019 VA examination reflects that he was not working, at least in part, due to the fact that his wife was ill and that he had assumed the majority of housekeeping and childrearing duties. Additionally, treatment records, including June 2018 treatment records, reflect that his memory was grossly intact, his behavior was cooperative, his thought processes were linear, and that his judgment and insight were fair, weighing against finding that any difficulty in adapting to stressful circumstances was of a frequency, severity, and duration, such that the assignment of a disability rating in excess of 50 percent for his PTSD would be warranted. No other symptoms, including obsessional rituals that interfere with routine activities, speech that it intermittently illogical, obscure, or irrelevant, near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively, spatial disorientation, neglect of personal appearance and hygiene, and an inability to establish and maintain effective relationships are reflected by the Veteran's treatment records. For example, an October 2017 treatment record reflects that Veteran was appropriately dressed, was oriented to time, person, place, and situation, had a grossly intact memory, had cooperative behavior, had normal speech, had linear thought processes, had no hallucinations or delusional thoughts, and had fair judgment and insight. The March 2018 private treatment record reflects that his concentration was fair, his speech was coherent but rapid and uncertain at times, his affect was normal, his mood was average, but that his usual mood was "kind of happy," he denied obsessions, compulsions, paranoid ideas, and hallucinations, that he continued to have friends from church, his judgment was fair, his insight was fair, he was oriented to time, place, and person, his memory was somewhat spotty and in exact, and that he had difficulty, not an inability, to maintain effective work and social relationships. A June 2018 treatment record reflects that he had appropriate dress and hygiene, was cooperative, maintained good eye contact, had a full range of affect, had normal speech, had goal oriented thought processes, had logical thought processes, had an intact memory, had no psychosis, had good insight and judgment, and was oriented to time, person, place, and situation. Thus, a holistic analysis fails to show that the Veteran's PTSD has caused occupational and social impairment with deficiencies in most areas, the level of occupational and social impairment necessary for the assignment of a 70 percent disability rating. Next, although the general rating formula provides specific examples of symptoms that may result from various acquired psychiatric disabilities, the Board emphasizes that its analysis should not be limited to only these symptoms, but should also consider any other relevant criteria outside of the rating code in order to determine the level of occupational and social impairment. Mauerhan v. Principi, 16 Vet. App. 436, 444 (2002). Thus, the Board has also considered the extent to which there are other indications of occupational and social impairment with reduced reliability and productivity. In this regard, the evidence does not indicate that a disability rating in excess of 50 percent is warranted. Here, the evidence shows that although the Veteran reported he has difficulty maintaining a job, he worked for multiple years as an assistant manager at a pizza chain, has friends from church, has been married to and lives with his wife of nearly approximately 17 years, and his children, bowls competitively, and assumed the majority of the housekeeping and childrearing duties because his wife became ill. Therefore, the Veteran does not display occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood even when factoring in other relevant criteria outside of the rating code. See Mauerhan, 16 Vet. App. at 444. In considering the appropriate disability rating for the Veteran's PTSD, the Board has also considered the statements from the Veteran that it is worse than the rating he currently receives because, among other things, he has had passive suicidal thoughts, nightmares, and difficulty maintaining a job. 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). Competency of evidence differs from weight and credibility. Although the Veteran is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses, he is not competent to identify a specific level of disability of his PTSD according to the appropriate DC. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). On the other hand, such competent evidence concerning the nature and extent of the Veteran's PTSD has been provided by the medical personnel who have examined him during the current appeal and who have rendered pertinent opinions in conjunction with their evaluations. The medical findings of the February 2014 and June 2019 VA examiners (as provided in the examination reports) directly address the criteria under which his PTSD is evaluated. Their medical findings (and contemporaneous treatment records) do not show that his PTSD causes occupational and social impairment with deficiencies in most areas such as work, school, family relations, judgment, thinking, or mood. Thus, although the Veteran has asserted that his PTSD symptoms warrant a higher rating, the impact of his PTSD symptoms was discussed and addressed by the February 2014 and June 2019 VA examiners, and the Board finds their assessments of greater probative weight. Finally, the Board acknowledges the holding in Rice v. Shinseki, 22 Vet. App. 447 (2009), that a total disability rating based on individual unemployability (TDIU) claim is part of a claim for a higher rating when such claim is raised by the record or asserted by the Veteran. In this regard, the Veteran testified at his hearing that he has difficulty maintaining employment. Specifically that he has difficulty interacting with others. However, the Veteran did not mention that he was unemployed specifically, or that he believed he could not work. Therefore, based on this testimony alone, the Board does not conclude that a TDIU claim is not raised by the record at this time. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). By virtue of the foregoing, the Board concludes that an initial disability rating in excess of 50 percent for the Veteran's PTSD is not warranted. New and Material Evidence 2. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for sleep apnea, formerly claimed as a sleep condition 3. Whether new and material evidence has been submitted to reopen the claim of entitlement to service connection for gout, to include as secondary to a right knee disability The Veteran contends that his claims of entitlement to service connection for sleep apnea and gout should be reopened because the record now contains new evidence, which shows that his sleep apnea is etiologically related to his active duty service and that his gout is etiologically related to his active duty service or was the result of or aggravated by his service-connected right knee disability. In order for evidence to be sufficient to reopen a previously disallowed claim, it must be both new and material. If the evidence is new, but not material, the inquiry ends, and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999); Manio v. Derwinski, 1 Vet. App. 140 (1991). Under the relevant regulations, "new" evidence is defined as evidence not previously submitted to agency decision-makers. 38 C.F.R. § 3.156(a). "Material" evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. If it finds that the submitted evidence is new and material, VA may then proceed to evaluate the merits of the claim on the basis of all evidence of record, but only after ensuring that the duty to assist the veteran in developing the facts necessary for the claim has been satisfied. See Elkins v. West, 12 Vet. App. 209 (1999). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low, and consideration is not limited to whether the newly submitted evidence relates specifically to the reason the claim was last denied. Rather, consideration should include whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the Secretary's duty to assist or through consideration of an alternative theory of entitlement. See Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010). Moreover, when determining whether the claim should be reopened, the credibility of the newly submitted evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). The Veteran's claim of entitlement to service connection for sleep apnea, formerly claimed as a sleep condition, was denied by an August 2006 rating decision on the ground that it did not occur in and was not caused by his active duty service. The Veteran's claim of entitlement to service connection for gout, to include as secondary to a right knee disability, was denied by a June 2015 rating decision on the ground that the evidence failed to show that his gout resulted from or was aggravated by his service-connected right knee disability or that he had gout during active duty service. The Veteran did not appeal the denial of these claims in the August 2006 and June 2015 rating decisions, nor did he submit any new and material evidence within a year of receiving them. Thus, the August 2006 rating decision represents the last final denial of his claim seeking service connection for sleep apnea, and the June 2015 rating decision represents the last final denial of his claim seeking service connection for gout. See Buie v. Shinseki, 24 Vet. App. 242, 252 (2011). The Board notes that although he filed a new claim seeking service connection for gout in July 2015, he did not file a notice of disagreement on the prescribed form, and therefore a notice of disagreement will not be implied. Regardless, as set forth below, the Board finds that new and material evidence has been submitted to reopen his claim of service connection for gout, and there is no prejudice to the Veteran. After a review of the evidence submitted since the August 2006 and June 2015 rating decisions became final, the Board determines that the Veteran's claims of entitlement to service connection for sleep apnea and gout should be reopened. The record now includes new evidence, including his testimony at the June 2021 Board hearing, the report from the June 2017 VA examination, and treatment records, which raise the possibility that he has sleep apnea and gout, and that they may be etiologically related to his active duty service. Not only is this evidence "new" because it was not of record prior to the last final denial of the claims, it is also "material" because it relates to unestablished facts necessary to support the claims. Therefore, his claims seeking service connection for sleep apnea and gout should be reopened. Shade, 24 Vet. App. at 118-21; see also 38 C.F.R. § 3.156(a). Service Connection The Veteran contends that service connection is warranted for sleep apnea and gout. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110. Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases may be presumed to have been incurred during service if they become manifested to a compensable degree within one year from separation from service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). This presumption is rebuttable by affirmative evidence to the contrary. Id. Moreover, evidence of continuous symptoms since active duty is a factor for consideration as to whether a causal relationship exists between an in-service injury or incident and the current disorder as is contemplated under 38 C.F.R. § 3.303(a). Service connection is also warranted for a disability that is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). Accordingly, when service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. 4. Entitlement to service connection for sleep apnea, formerly claimed as a sleep condition The Veteran contends that service connection is warranted for sleep apnea because his snoring during active duty service shows that sleep apnea began during his active duty service. In this regard, the Board notes that the Veteran has often characterized this claim as one for "difficulty sleeping." To the extent that he may have any symptoms related to insomnia, such symptoms are already captured in the 50 percent rating he received for his acquired psychiatric disorder. Therefore, this issue is more specifically directed toward his statements regarding sleep apnea. It is well-established that service connection may only be granted for a current disability, and therefore, when a claimed condition is not shown, there may be no grant of service connection. 38 U.S.C. § 1110; Rabideau v. Derwinski, 2 Vet. App. 141 (1992) (Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability). "In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Based upon the evidence of record, the Board concludes that service connection for sleep apnea is not warranted because the Veteran does not have a diagnosis of sleep apnea and has not had such a diagnosis at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303 (a), (d). Specifically, the Board finds that after a thorough reading of the evidence of record, the evidence does not reflect a current diagnosis related to sleep apnea. The Board acknowledges the assertions by the Veteran that he has symptoms of sleep apnea, including that he snored during active duty and currently has nightmares and other difficulties sleeping. However, he is not competent to provide a diagnosis. The issue of whether he has sleep apnea is medically complex and requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Therefore, the preponderance of the evidence is against a finding that the Veteran has had sleep apnea at any point during this appeal. See 38 U.S.C. § 1110; Rabideau, 2 Vet. App. 141. Accordingly, the Board finds that service connection for sleep apnea is not warranted. 5. Entitlement to service connection for gout, to include as secondary to a right knee disability The Veteran contends that service connection is warranted for gout because he began experiencing pain related to gout after he separated from active duty service, and that the boots he wore during active duty service caused his gout. He further contends that service connection for gout is warranted because it has been caused or aggravated by his right knee disability because his gout is also in his right leg. Initially, the Board finds that the Veteran's service treatment records fail to establish that his gout began during or is otherwise etiologically related to his active duty service. Indeed, a November 2003 treatment record reflects that he denied arthritis, rheumatism, and painful joints, and did not indicate that he had gout. Similarly, a September 2004 report of medical assessment reflects that he had no questions or concerns about his health, had no injuries that caused him to miss duty for longer than three days, and did not report any symptoms that could be related to gout. Given that he did not seek treatment for, report signs or symptoms of, or receive a diagnosis of gout during his active duty service, his service treatment records do not show that his gout began during or is otherwise etiologically related to his active duty service. Accordingly, his service treatment records fail to establish that service connection for gout is warranted. The post-service clinical evidence also fails to establish a relationship between the Veteran's gout and his active duty service. In this case, the post-service clinical evidence of record does not reflect that he sought treatment for or reported signs or symptoms of a left hip disorder until December 2011, approximately seven years after his separation from service. Given that gap, a continuity of symptoms based upon the clinical evidence is not sufficient to support a direct nexus for the Veteran's gout. The Board acknowledges the Veteran's statements regarding the history of his symptoms of gout. Although he is competent to report that he has experienced symptoms of gout, he is not competent to determine that these symptoms were manifestations of a particular disorder. See Jandreau, 492 F.3d at 1377, 1377 n.4. Nevertheless, to the extent he contends that his gout was caused by active duty service, including the boots that he wore during active duty service, and has persisted since service, the Board determines that the reported history of continued symptoms is not credible or probative. Indeed, the contention that he has experienced continuous symptoms of these disorder is not credible given that a report of medical assessment from only three months before his separation from service reflects that he did not report that he experienced symptoms or gout and that he did not seek treatment for or report symptoms of gout until approximately seven years after his separation from service. See Kahana v. Shinseki, 24 Vet. App. 428, 439-40 (2011). Next, service connection may be granted when the evidence establishes a medical nexus between active duty service and the current diagnosis. However, there is not sufficient evidence in the medical records to demonstrate a nexus between his active duty service and his bilateral hip disorder, right knee disorder, tremors of the bilateral upper extremities, neuropathy of the bilateral lower extremities, and chronic joint pain. Indeed, there is no objective medical evidence linking these disorders to his active duty service. The Board also places significant probative weight on the report from the May 2017 VA examination. The examination report reflects that the examiner opined that the Veteran's gout was less likely than not proximately due to or the result of his service-connected right knee disability. In support of that opinion, the examiner explained that the causes of gout are related to excessive amounts of Uric acid in the blood, which may result in the formation of hard crystals in the joints, and that gout is not caused by any type of medical procedure, including the medical procedure performed on the Veteran's right knee. The Board concludes that the examiner's opinion is entitled to significant probative weight given the examiner's in-person examination, review of the claims file, thorough rationale, and citation of medical literature supporting his rationale. In arriving at its conclusion, the Board has also considered the statements made by the Veteran relating his gout to his active duty service and his service-connected right knee disability. The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (quoting Jandreau, 492 F.3d at 1377). In this case, however, the Veteran is not competent to provide testimony regarding the etiology of his gout. See Jandreau, 492 F.3d at 1377, n.4. Although the Veteran can provide competent testimony regarding symptoms, gout is not a disorder that can be diagnosed by its unique and identifiable features as it does not involve a simple identification that a layperson is competent to make. In any event, the diagnoses of dysfunctions and disorders, and their respective etiologies, are medical determinations and generally must be established by medical findings and opinion. See id. at 1376-77. Thus, to the extent that the Veteran believes that his gout is related to his active duty service and/or his service-connected right knee disability, he is a lay person without appropriate medical training and expertise to provide a medical diagnosis and etiological opinion. By virtue of the foregoing, the Board concludes that service connection is not warranted for his gout. 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. B.T. KNOPE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Crosnicker, Associate Counsel