Citation Nr: A21018048 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 210629-169338 DATE: November 9, 2021 ORDER Entitlement to an initial rating in excess of 40 percent for patellar tendonitis of the right knee with limitation of extension is denied. Entitlement to a separate rating of 20 percent for patellar tendonitis of the right knee due to a meniscal cartilage injury with episodes of frequent locking, effusion and pain, is granted. Entitlement to an initial rating in excess of 40 percent for chondromalacia patella of the left knee, status-post arthroscopic surgery, with limitation of extension is denied. Entitlement to a separate rating of 20 percent for patellar tendonitis of the left knee due to a meniscal cartilage injury with episodes of frequent locking, effusion and pain, is granted. Entitlement to service connection for colon cancer is denied. Entitlement to service connection of left foot calcaneal spur, osteoarthritis, and metatarsalgia is granted Entitlement to service connection of bilateral hip strain with osteoarthritis is granted. Entitlement to service connection of bilateral shoulder strain with tendonitis and degenerative arthritis is denied. Entitlement to service connection of bilateral hand/finger strain is denied. Entitlement to service connection for glaucoma of the left eye is denied. Entitlement to service connection of sleep apnea is denied. Entitlement to service connection of a breathing disability is denied. FINDINGS OF FACT 1. The Veteran's right knee disability has not resulted in extension limited to 45 degrees or less; he has not shown compensable limitation of flexion and there is no evidence of recurrent subluxation or instability of the knee; the knee disability has resulted in a confirmed meniscal condition with episodes of frequent locking, pain and effusion into the joint. 2. The Veteran's left knee disability has not resulted in extension limited to 45 degrees or less; he has not shown compensable limitation of flexion and there is no evidence of recurrent subluxation or instability of the knee; the knee disability has resulted in a confirmed meniscal condition with episodes of frequent locking, pain and effusion into the joint. 3. The Veteran's colon cancer did not have onset until many years after service, and is less likely than not related to any incident of active service, to include any solvent exposures during service at Camp Lejeune. 4. The Veteran's left foot calcaneal spur, osteoarthritis, and metatarsalgia is at least as likely as not related to his occupational work as a supply personnel in service, or to his service-connected bilateral knee disability. 5. The Veteran's bilateral hip strain with osteoarthritis is at least as likely as not related to his occupational work as a supply personnel in service, or to his service-connected bilateral knee disability. 6. The Veteran's bilateral shoulder strain with tendonitis and degenerative arthritis is less likely than not related to any incident of active service, to include solvent exposures at Camp Lejeune. 7. The Veteran's bilateral hand/finger strain is less likely than not related to any incident of active service, to include solvent exposures at Camp Lejeune. 8. The Veteran's left eye glaucoma did not have onset until many years after service, and is less likely than not related to any incident of active service, to include any solvent exposures during service at Camp Lejeune. 9. The Veteran's sleep apnea did not have onset during service and is not otherwise related to any incident of active service, to include any solvent exposure during service at Camp Lejeune. 10. The Veteran's current bronchitis with old histoplasmosis did not have onset during active service and is not otherwise related to any incident of active service, to include solvent exposure at Camp Lejeune. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 40 percent for patellar tendonitis of the right knee with limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes (DCs) 5257, 5260, 5261. 2. The criteria for a separate rating of 20 percent for patellar tendonitis of the right knee with frequent episodes of locking, pain and effusion into the joint have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5258. 3. The criteria for a rating in excess of 40 percent for chondromalacia patella of the left knee, status-post arthroscopic surgery, with limitation of extension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Codes (DCs) 5257, 5260, 5261. 4. The criteria for a separate rating of 20 percent for chondromalacia patella of the left knee, status-post arthroscopic surgery, with frequent episodes of locking, pain and effusion into the joint have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5258. 5. The criteria for service connection for colon cancer are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 6. The criteria for service connection for left foot calcaneal spur, osteoarthritis, and metatarsalgia as directly related to active service or secondary to service-connected knee disabilities are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 7. The criteria for service connection for bilateral hip strain with osteoarthritis as directly related to active service or secondary to service-connected knee disabilities are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 8. The criteria for service connection for bilateral shoulder strain with tendonitis and degenerative arthritis are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 9. The criteria for service connection for bilateral hand/finger strain are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 10. The criteria for service connection for left eye glaucoma are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 11. The criteria for service connection for sleep apnea are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 12. The criteria for service connection for chronic bronchitis with old histoplasmosis are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June to August 1980, from May 1982 to July 1985, and from December 1987 to September 1990. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2021 supplemental statement of the case issued by a Department of Veterans Affairs (VA) Regional Office (RO). This appeal comes before the Board subject to the Modernized system of review under the Appeals Modernization Act (AMA). As a matter of procedural background, a rating decision was issued under the legacy system in January 2014 and the Veteran submitted a timely notice of disagreement. The appeal progressed under the Legacy system of review, and in October 2018, the Board issued a decision/remand in this matter which, among other things, remanded the seven issues presently part of this appeal for further development. That development resulted in a supplemental statement of the case which was issued in May 2021. The Veteran opted the claims into the Modernized review system pursuant to the AMA by submitting a June 2021 VA Form 10182, Decision Review Request: Board Appeal, identifying the May 2021 supplemental statement of the case. Therefore the May 2021 supplemental statement of the case is the decision on appeal. In the June 2021 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Evidence Submission docket. Therefore, the Board may only consider the evidence of record at the time of the May 2021 supplemental statement of the case, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. Additionally, The Board notes that in June 2021, the Veteran submitted a VA Form 10182 that was incomplete as it did not identify an Appeal Review option, nor did it specifically request to opt-into AMA from the most recent supplemental statement of the case. That correspondence was accompanied by a statement from the Veteran's attorney indicating a desire to withdraw the increased rating claims for the right and left knee. However, shortly thereafter, the Veteran's attorney submitted a second VA Form 10182, which did elect a review lane (Evidence Submission), specifically opted-into AMA from the May 2021 supplemental statement of the case, and also included the increased knee rating claims. A withdrawal of a claim is only effective when it is explicit, unambiguous, and done with a full understanding of the consequences of such action. Delisio v. Shinseki, 25 Vet. App. 45, 57 (2011). In this matter, the Board does not find that the withdrawal was explicit or unambiguous, as a later VA Form 10182, which was complete, included the increased rating claims. It is also unclear from the statement, particularly as the VA Form 10182 also served to withdraw the appeals from the legacy system of appeals and move them to AMA, whether the Veteran, via his attorney, sought to withdraw the appeals themselves from consideration, or simply to move them to the Modernized system of review. As such, the Board cannot accept the "withdrawal" submitted with the initial VA Form 10182 because it is not unambiguous in its intentions. In continuing to include the increased rating claim in the appeal, the Board notes that the Veteran is in no way prejudiced by the Board's actions, indeed, the below decision grants additional benefits to the Veteran he would not otherwise receive but for the Board adjudicating the claim herein. Finally, the Veteran appealed a claim of service connection of multiple joint arthritis. During the pendency of this appeal, the Veteran was variously diagnosed with left and right knee disabilities (already service-connected); calcaneal spur, osteoarthritis and metatarsalgia of the left foot; bilateral hip strain; bilateral shoulder strain; and bilateral hand/finger strain. As these diagnoses may all be attributed to the claimed multi-joint arthritis, the Board has recharacterized the appeal to reflect each diagnosed condition. Increased Ratings Disability ratings are determined by the application of a schedule of ratings, which is based on the average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. The Veteran's entire history is reviewed when making disability evaluations. See generally, Schafrath v. Derwinski, 1 Vet. App. 589 (1991); 38 C.F.R. § 4.1. Where, as in the case of the Veteran's bilateral knee disabilities, the question for consideration is the propriety of the initial evaluation assigned, consideration of the medical evidence since the effective date of the award of service connection and consideration of the appropriateness of staged ratings are required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Further, "[w]here there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned." 38 C.F.R. § 4.7. 1. Entitlement to an initial rating in excess of 40 percent for patellar tendonitis of the right knee with limitation of extension 2. Entitlement to an initial rating in excess of 40 percent for chondromalacia patella of the left knee, status-post arthroscopic surgery, with limitation of extension The Veteran's right and left knee disabilities are rated as 40 percent disabling each for the period on appeal. He seeks higher ratings. The Board finds that the claims should be denied. The Veteran's right knee disability, which is described as limited extension due to patellar tendonitis, is rated pursuant to Diagnostic Code (DC) 5024-5261. Hyphenated Diagnostic Codes are used when a rating under one code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. 38 C.F.R. § 4.27. In this case, DC 5024 indicates tenosynovitis, tendinitis, tendinosis or tendinopathy. Pursuant to the applicable rating criteria, such a disability is to be rated as degenerative arthritis, based on limitation of motion of the affected parts. 38 C.F.R. § 4.71a, DC 5024. DC 5261 indicates limitation of extension. The Veteran's left knee disability, which is described as limitation of extension, status-post arthroscopic surgery for chondromalacia patella, is rated pursuant to DC 5259-5261. In this case, DC 5259 indicates symptomatic removal of the semilunar cartilage. DC 5261 indicates limitation of extension. DC 5261 rates knee disabilities based on limitation of extension. Extension limited to 30 degrees or more is granted a 40 percent rating. Extension limited to 45 degrees or more is granted a maximum 50 percent rating. When rating based on limitation of motion, a separate rating may be assigned for knee disabilities based on limitation of flexion as well as limitation of extension of the knee if both pathologies exist. Likewise, separate ratings may be assigned based on limitation of motion, as well as instability or subluxation, or joint locking and effusion due to semilunar cartilage issues, if found. See VAOPGCPREC 23-97 (Multiple Ratings for Knee Disability). For the reasons discussed below, the Board does not find that instability or subluxation, has been found to warrant a separate rating. The Board does note that for a rating based on limitation of flexion, flexion must be limited to 45 degrees or less to warrant a compensable rating. 38 C.F.R. § 4.71a, DC 5260. Additionally, the Board notes that semilunar cartilage issues, particularly a dislocation with frequent episodes of "locking," pain and effusion may warrant a 20 percent rating. 38 C.F.R. § 4.71a, DC 5258. When the semilunar cartilage has been removed but remains symptomatic, a 10 percent rating is assigned. 38 C.F.R. § 4.71a, DC 5259. It should be noted that, during the course of this appeal, the schedular criteria for evaluating the knee have been amended. Specifically, the criteria pertaining to (1) nomenclature in DC 5024, and (2) the ratings for knee instability under DC 5257, was amended effective February 7, 2021. See 85 Fed. Reg. 76,453 (November 30, 2020). Where a law or regulation changes during the pendency of a claim for increased rating, the Board should first determine whether application of the revised version would produce retroactive results. In particular, a new rule may not extinguish any rights or benefits the claimant had prior to enactment of the new rule. VAOPGCPREC 07-03 (November 19, 2003). However, if the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Karnas v. Derwinski, 1 Vet. App. 308, 313 (1991), overruled in part, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). As the Veteran's claim was received prior to the effective date of the regulation changes, the Board must consider the Veteran's knee disabilities under both the old and the revised rating criteria and must apply the old rating criteria if the result is more favorable to the Veteran. Id. However, in this matter the Board finds that such consideration is minimal at most. Particularly, the criteria in DC 5024 was amended to clarify a rating as degenerative arthritis, but continues to instruct that the disability be rated based on motion-based diagnostic criteria. As noted in more detail below, the Board has not found evidence of recurrent subluxation or instability in the knee, and therefore DC 5257 is not for general consideration. The Veteran was initially afforded a VA examination in connection with his increased rating claim in September 2012. At that time patellar tendonitis was diagnosed bilaterally. He reported flare-ups consisting of buckling with painful walking. flexion was limited to 110 degrees in the right knee and 120 degrees in the left knee. Extension was limited to 35 degrees bilaterally. Pain was observed at the terminal degrees of movement. No additional loss of movement was observed on repetitive use testing. No additional factors contributed to his disability. Muscle strength was normal bilaterally on extension and flexion. Joint stability testing was normal bilaterally on all planes of movement. No patellar subluxation or dislocation was identified. A left knee meniscectomy had been completed in November 1981, with tenderness to palpation in the medial joint line, but no other symptoms beyond the loss of range of motion. He occasionally used a brace to ambulate. Functionally, the examiner stated that he was unable to engage in active employment due to his knees, but could engage in sedentary employment such as counseling. He was noted to have worked previously in hotel management, but left a year and a half earlier due to colon cancer, and not having to do with his knees. In September 2020, a new VA examination was conducted of the Veteran's knees. Although that examination focused on the left knee, it did evaluate both the left and right knee. He reported daily pain 4/10 in severity, going up to 10/10 in severity when aggravated. Aggravation occurred due to prolonged walking, standing and using stairs. He complained of some swelling at the end of the day. he reported feeling that his knees were frozen when getting up in the morning, and reported buckling. Flare-ups were described a buckling with limitation of bending due to decreased range of motion. Flexion was to 60 degrees in the right knee and 80 degrees in the left. Extension was limited to 10 degrees bilaterally. Pain was noted at the terminal points of movement, with limitation of movement preventing squatting, and the same range of motion findings were noted in active vs. passive and weight bearing vs. non-weight bearing movement. Localized tenderness and crepitus were found bilaterally. No additional functional loss was observed on repetitive movement, and the examination was medically consistent with the Veteran's reports of functional loss with repeated use over time. In terms of range of motion with loss over time and during periods of flare, the examiner estimated that the right knee would be limited to 50 degrees of flexion and 20 degrees of extension, and the left knee would be limited to 70 degrees of flexion and 20 degrees of extension. Bilaterally, the examiner found swelling at the end of the day; instability of station, which was specifically descried as pain with prolonged standing; disturbance of locomotion, described as pain with prolonged walking and standing and antalgic gait; and interference with prolonged standing due to pain. Strength showed active movement against some resistance bilaterally, with no evidence of muscle atrophy. There was no evidence of ankylosis or fixation of the joints. Joint stability testing found no clinical or actual evidence of lateral instability or recurrent subluxation. Anterior, posterior, medial, and lateral stability were all normal. There was no evidence of a recurrent patellar dislocation. A meniscal tear identified in 1989 was noted, but was not identified as symptomatic. Functionally, the examiner stated that the condition interfered Shortly thereafter, in October 2020, a new VA examination was conducted which assessed the severity of his knee disabilities. The Veteran reported pain worse with ambulation. Flare-ups occurred several times per week, lasting several hours, and alleviated by rest, and resulting in increased pain and decreased range of motion. Range of motion showed flexion limited to 120 degrees and extension limited to 10 degrees. Pain was found at the terminal degrees causing functional loss. There was evidence of mild localized tenderness in the anterior knee, with evidence of crepitus. No pain was found with weight bearing. No additional functional loss was found on repetitive use testing, and the examination was neither medically consistent nor inconsistent with the Veteran's statements describing functional loss with use over time or during periods of flare. He reported buckling. Strength was normal bilaterally and he did not have atrophy of the muscles. No ankylosis or fixation of the joint was noted. Joint stability testing was normal on all planes. A positive McMurray's test identified a meniscal tear bilaterally, with episodes of joint effusion and buckling of the knees. No residuals of his meniscectomy were identified. Functionally, the knee disability resulted in decreased range of motion and increased pain. Based on the available evidence, the Board does not find that an increased rating in excess of 40 percent for either based on limitation of extension is warranted. At no point has the Veteran been found to have extension limited to 45 degrees or more, indeed, at most he showed limitation to 35 degrees in 2012. Most recently, his limitation of extension has improved dramatically, although the RO has not found those results sufficient to warrant a rating reduction, and the Board will not disturb the maximum benefit already in effect. The Board has considered whether a separate rating based on limitation of flexion is warranted, but finds that it is not. Even considering use over time and during periods of flare, the Veteran's right knee has at most been limited to 50 degrees of flexion, and the left to 70 degrees of flexion. However, these findings do not rise to the 45 degrees of limitation required for a compensable rating based on limitation of flexion. Therefore, although flexion is limited, it does not rise to a compensable level, and a separate rating is not granted. Turning to the question of whether a rating should be assigned based on either recurrent instability or subluxation, the Veteran's knee stability has been tested frequently throughout the appeal period, with no actual evidence of subluxation or instability. Although he used a brace in 2012, there is no indication that was prescribed by a physician. Further, as recently as October 2020, he denied using any assistive devices to ambulate. There is no actual diagnosis of any type of instability. As such, a separate rating based on instability is not supported. However, the Board does find that a separate 20 percent rating should be assigned based on an injury to the semilunar cartilage, for both knees with evidence of locking, pain and effusion in the joints. The Veteran has a confirmed meniscal cartilage tear in both knees, with arthroscopic surgery in the left knee in 1989, during service. This cartilage issue continues to be symptomatic to the present. He has positive grinding tests as recently as October 2020. Further, the Veteran has reported, and all three examiners have identified frequent episodes of "buckling" and locking of the knee. Swelling and effusion has also been noted in the joint with increased pain throughout both knees, regardless of range of motion. As such, the Board will afford the Veteran the benefit of the doubt and assign a separate 20 percent rating for each knee under DC 5258, which compensates for locking of the knee with effusion into the joint, due to cartilage issues, which are separate from his reduced extension. In sum, the Board finds that a rating in excess of 40 percent each for the right and left knee based on limitation of extension is not supported. Neither is a separate rating based on limitation of flexion or the presence of instability or subluxation. To this extent, the appeal is denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. However, the Board does finds that a separate 20 percent rating for each knee based on injury to the meniscal cartilage with frequent episodes of locking, effusion and pain is supported. To this extent the appeal is granted. Service Connection The law provides that service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). In addition, certain chronic diseases, including arthritis, may be presumed to have been incurred during service if the disorder becomes manifest to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Regardless of whether a condition is listed as chronic for presumptive purposes, a continuity of symptoms from the time of service is a factor to consider in assessing any claim. Effective March 14, 2017, VA amended its adjudication regulations relating to presumptive service connection, adding eight diseases that are associated with contaminants present in the water supply at Camp Lejeune. As of the writing of this decision, the diseases for which presumptive service connection may be granted based on solvents in the drinking water at Camp Lejeune are limited to kidney cancer, liver cancer, Non-Hodgkin's lymphoma, adult leukemia, multiple myeloma, Parkinson's disease, aplastic anemia and other myelodysplastic syndromes, and bladder cancer. 38 C.F.R. §§ 3.307, 3.309(f). A disability may also be found service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310. 3. Entitlement to service connection for colon cancer The Veteran seeks service connection of colon cancer. The Board finds that the claim should be denied. Initially, the Board recognizes a present diagnosis of colon cancer, in remission, diagnosed in June 2011. A review of the Veteran's service treatment records does not document any evidence of colon cancer. There are no colon-related complaints contained therein. There is no evidence of any incident or injury to the colon during active service. In short, there is no in-service incident, illness or injury to which the colon cancer, as diagnosed in 2011, could be etiologically linked. However, for his part, the Veteran asserts that solvent exposure during service at Camp Lejeune is the cause of his colon cancer. The record does reflect that he served at Camp Lejeune in 1983. Colon cancer is not one of the diseases for which presumptive service connection may be granted based on solvents in the drinking water at Camp Lejeune. 38 C.F.R. §§ 3.307, 3.309(f). However, that a disability is not codified as presumptive does not explicitly rule out service connection of that disability, presuming the claimant can establish service connection on a direct basis. As such, the question then becomes whether or not the Veteran's colon cancer is at least as likely as not related to any solvent exposure. In light of the Veteran's service at Camp Lejeune in 1983, the Board remanded this appeal so that a VA examination could be conducted, and a medical opinion obtained. In January 2021, a VA examination was conducted which included a physical evaluation and taking a complete medical history from the Veteran. The examiner reviewed the complete claims file and concluded that it was less likely than not that the Veteran's colon cancer was related to any incident of active service, including service at Camp Lejeune. In support of this, the examiner noted that the colon cancer was not diagnosed until many years after the purported exposure and was presently in remission. Colorectal cancer is a multifactorial disease process. Genetic factors, environmental exposures such as diet, and inflammatory conditions of the digestive tract are all involved in the development of colorectal cancer. The examiner cited to published medical treatise evidence in support of this conclusion. The Board finds this opinion to be particularly persuasive. It was rendered by a medical specialist in contemplation of the complete medical record, which included a physical examination of the Veteran and application of the facts of this specific case to known medical principles and medical treatise evidence. The Board has reviewed the evidence of record but finds no medical evidence or opinion that would contradict those of the medical examiner. The Board does acknowledge the Veteran's own firmly held belief that his condition is related to service at Camp LeJeune, but does not find this to be persuasive. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his colon cancer, especially in light of the VA specialist's conclusions to the contrary and the fact that the evidence fails to demonstrate the onset of colon cancer or any other colon-related complaints in service. See id. In sum, the Board finds that the Veteran's colon cancer is less likely than not related to any incident of active service, particularly his service at Camp LeJeune. As such, the claim fails the third prong of service connection, and it must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 4. Entitlement to service connection for calcaneal spur, osteoarthritis and metatarsalgia of the left foot, and bilateral hip strain with osteoarthritis, claimed as multiple-joint arthritis 5. Entitlement to service connection for bilateral shoulder strain and bilateral hand/finger strain, claimed as multiple-joint arthritis The Veteran seeks service connection of multiple joint arthritis. The Board finds that the hip and foot claims should be granted, but that the shoulder and hand/finger claims should be denied. In January 2021, the Veteran underwent multiple VA examinations to assess his various complaints of arthritis. At that time, the Veteran was diagnosed with calcaneal spur, osteoarthritis, and metatarsalgia of the left foot; bilateral hip strain; bilateral shoulder strain, tendonitis, and osteoarthritis; and bilateral hand/finger strain. For his part, the Veteran asserts that his joint issues are related to his occupational specialty as a supply personnel, with years of repetitive motion, frequent heavy lifting and being on his feet consistently throughout service. He has also alleged that his arthritis may be related to solvent exposures while stationed at Camp Lejeune. The Board notes that arthritis and joint strain are not disabilities for which service connection is granted presumptive of exposure at Camp Lejeune. The Board remanded the claim of service connection of multiple joint arthritis in October 2018 so that a VA examination and medical opinion could be obtained. In June 2020 a Camp Lejeune subject matter expert reviewed the complete claims file and concluded that the Veteran's degenerative joint disease or osteoarthritis was less likely than no related to exposures during active service. In support of this, the examiner noted that the Veteran had other, more accepted risk factors for arthritis, to include aging and obesity. Further, the medical evidence does not currently support a causal relationship between solvent exposures at Camp Lejeune and degenerative joint issues. The Board finds this opinion to be generally persuasive of the question of service connection secondary to solvent exposure. It was given following a complete review of the medical file, and applied the facts of this case to known medical principles. There is no medical evidence or opinion of record to contradict this conclusion. However, in January 2021, the Veteran was afforded a physical examination of his various joints. At that time, the Veteran was diagnosed with bilateral shoulder strain/tendonitis/arthritis and bilateral hand/finger strain. After the physical evaluation, the examiner reviewed the complete medical history and concluded that those diagnoses were less likely than not related to any incident of active service. In support of this, the examiner noted that the Veteran's bilateral shoulder and hand strain were not noted during active service. They were not complained of or noted until many years following separation from service in July 2014. Thus, they were less likely than not related to any incident of active service, to include his occupational specialty. The Board finds this opinion to be generally persuasive as it was given by a medical specialist in contemplation of the complete medical record and applied known medical principles to the facts of the case. The Board does acknowledge the Veteran's own firmly held belief that his hand and shoulder disabilities are related to service at active service, to include his occupational specialty and service at Camp LeJeune, but does not find this to be persuasive. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his hand or shoulder disabilities, especially in light of the multiple VA specialist's conclusions to the contrary and the fact that the evidence fails to demonstrate the onset of any hand or shoulder symptoms or issues until many years after separation from service. See id. Turning to the Veteran's diagnosed bilateral hip strain and left foot diagnoses, the January 2021 examiner noted that the Veteran's service treatment records did not show foot complaints. Nevertheless, the day-to-day duties as a supply personnel, and his service-connected left knee disability contributed to his disability. Over time, he developed a calcaneal spur, osteoarthritis, and metatarsalgia of the left foot. The kinetic chain theory can be applied as an abnormal gait from the left knee can affect the lower limbs. The modification of the movement and posture during pain leads to compensating by changing the demands of the muscles and soft tissue connected to the affected joints, leading to osteoarthritis and bone spurs. Thus, the various diagnosed left foot conditions were more likely than not related to his period of active duty service. Likewise, while his service treatment records did not record hip complaints, the development of his hip pain could be attributed to the day-to-day duties as a supply personnel, as well as his bilateral knee condition. Medical literature revealed that hip strain occurs when one of the muscle supporting the hip joint is stretched beyond its limit or is torn. The kinetic theory can also be applied with this claim as the abnormal gait further aggravated the hip pain due to the gait alteration. Thus, the bilateral hip strain and osteoarthritis of the hips are at least as likely due to active service. The Board similarly finds these opinions to be persuasive. The Veteran has a diagnosis associated with his bilateral hips and his left foot, which have found to be directly related to his active service, as well as to his bilateral service-connected knee disabilities. Those opinions offer a detailed explanation for how they were reached, and cited to specific medical treatise evidence in support of the conclusions. The Board has not identified any specific evidence to contradict these conclusions. As such, affording the Veteran the benefit of the doubt, service-connection of a left foot and bilateral hip disabilities should be granted. In sum, the Board finds that the bilateral hip and left foot disabilities are at least as likely as not related to service. As such, they are granted. However, the bilateral shoulder and hand claims are less likely than not related to any incident of active service to include any exposure events, and did not have onset until many years following service. As such, they must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 6. Entitlement to service connection for glaucoma of the left eye The Veteran seeks service connection of glaucoma of the left eye. The Board finds the claims should be denied. Initially, the Board recognizes a present diagnosis of glaucoma. A review of his service treatment records do not document any eye-related incident, injuries or illnesses during active service, nor has the Veteran made any such assertion. Rather, the Veteran asserts that his present glaucoma is related to solvent exposures while stationed at Camp Lejeune. The Board notes that glaucoma is not a disability for which service connection is granted presumptive of exposures at Camp Lejeune. In October 2018, the Board remanded this claim so that a medical opinion could be obtained which fully assesses the claim. In June 2020 a Camp Lejeune subject matter expert provided a medical opinion following a review of the complete claims file. The examiner concluded that the glaucoma was less likely than not related to exposures at Camp Lejeune because the Veteran has multiple other risk factors for that disability, including hypertension, diabetes and race. He also has a family history of hypertension and diabetes. In addition, the weight of the medical evidence does not currently support a causal relationship between solvent exposure and glaucoma. In May 2021, a VA examination was conducted which confirmed the findings of the Camp Lejeune subject matter expert. The examiner conducted a physical examination of the Veteran and reviewed the complete medical history. The examiner then concluded that the claimed glaucoma is less likely than not related to any incident of active service. In support of this, the examiner noted that glaucoma incidence increases with age and is a degeneration, not caused by any known injury ot event. In this case, the glaucoma did not occur until 18 years after separation from service. The Board finds these opinions persuasive. They were given by medical specialists in contemplation of the complete medical record and applied the facts of this specific case to known medical principles. The Board has reviewed the record but finds no medical evidence or opinions to contradict the opinions of the VA examiners. The Board does acknowledge the Veteran's own firmly held belief that his glaucoma of the left eye is related to service at Camp LeJeune, but does not find this to be persuasive. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his glaucoma, especially in light of the multiple VA specialist's conclusions to the contrary and the fact that the evidence fails to demonstrate the onset of any vision related issues until many years after separation from service. See id. In sum, the Board finds that the Veteran's left eye is less likely than not related to any incident of active service, particularly his service at Camp LeJeune. As such, the claim fails the third prong of service connection, and it must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 7. Entitlement to service connection of sleep apnea The Veteran seeks service connection of sleep apnea. The Board finds that the claim should be denied. Initially, the Board recognizes that the Veteran was diagnosed with sleep apnea in July 2005, many years after separation from active service. His service treatment records are general void of any evidence of sleep apnea or other breathing difficulties, and there is no evidence of continuity of symptoms from the time of service. For his part, the Veteran has asserted that his sleep apnea is related to solvent exposure at Camp Lejeune. In light of the Veteran's assertion, he was afforded a VA examination in December 2019. At that time the examiner confirmed his present diagnosis of sleep apnea, but concluded that it was less likely than not related to any incident of active service. In support of this, the examiner noted that the service medical records were unremarkable for sleep apnea symptoms or diagnosis, and the actual diagnosis did not occur until many years after separation from service. Absent some type of continuity of symptoms from the time of service, a nexus could not be established. In June 2020, a review of the record was conducted by a VA specialist. The examiner reviewed the complete medical history and claims file and concluded that the Veteran's sleep apnea was less likely than not related to any exposures at Camp Lejeune. In support of this, the examiner noted that the weight of the medical evidence did not support a causal relationship between sleep apnea and solvent exposure. Rather, other factors were more likely the cause of the sleep apnea disability, notably, the Veteran had significant risk factors to include obesity and gender. The Board finds these opinions persuasive. They were given by medical specialists in contemplation of the complete medical record and applied the facts of this specific case to known medical principles. The Board has reviewed the record but finds no medical evidence or opinions to contradict the opinions of the VA examiners. The Board does acknowledge the Veteran's own firmly held belief that his condition is related to service at Camp LeJeune, but does not find this to be persuasive. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his sleep apnea, especially in light of the VA specialist's conclusions to the contrary and the fact that the evidence fails to demonstrate the onset of any sleep apnea or any other breathing-related complaints until many years after separation from service. See id. In sum, the Board finds that the Veteran's sleep apnea is less likely than not related to any incident of active service, particularly his service at Camp LeJeune. As such, the claim fails the third prong of service connection, and it must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 7. Entitlement to service connection of a breathing disability The Veteran seeks service connection of a breathing disability, which following the most recent remand in this matter has been presently diagnosed as chronic bronchitis. The Board finds that the claim should be denied. The Veteran has a present diagnosis of bronchitis, identified as a bronchogenic cyst with a history of histoplasmosis. A review of the record indicates that in March 1990, shortly before he separated from active service, he was noted to have several granulomas in the lung, although they were identified as old, and no present respiratory or pulmonary disability was identified at that time. For his part, the Veteran has variously stated that he developed a chronic cough during the final years of active service, with continuity to the present. He also asserts that his present diagnosis is related ot solvent exposure at Camp LeJeune. Initially, the Board notes that the records does not support a continuity of symptoms from the times of service. Although the Veteran is competent to report observable symptoms such as a cough, once basic competency is met, the Board must assess the credibility of that testimony. In this case, there is no documented history of a chronic cough in service indeed, as late as March 1990, the Veteran was found to have no pulmonary or breathing issues, and despite a finding of several old granulomas, no chronic coughing was recorded. The Veteran did not seek treatment for a cough after service. Although some calcified granulomas were again identified in 1999, no chronic cough or respiratory issues were documented. He was not diagnosed with any type of cough-related symptoms or disability until 2006 sixteen years after separation when he was first diagnosed with bronchitis. Given the lack of corroborating medical records, the timing of the creation of his lay statements, and his self-interest in the outcome of the appeal, the Board does not find his testimony of onset in service credible for purposes of adjudicating this appeal. See Caluza v. Brown, 7 Vet. App. 498 (1995). Thus, a continuity of symptoms is not established. The Board previously remanded this appeal so that an opinion could be obtained which discussed a possible nexus to service. In June 2020, a Camp Lejeune subject matter expert reviewed the evidence and concluded that the Veteran's present respiratory issues were less likely than not related to any incident of active service, to include solvent exposures at Camp Lejeune. In support of this, the examiner noted that bronchogenic cysts were congenital in nature, whereas histoplasmosis is caused by breathing fungus spores. Thus, the weight of the medical evidence does not support a causal relationship between contaminated water at Camp Lejeune and bronchitis or histoplasmosis. An additional breathing examination conducted in October 2020 found a present diagnosis of chronic bronchitis. In January 2021, a medical opinion was given that found the present breathing disability and chronic cough was less likely than not incurred in military service. In support of this the examiner noted that there was no evidence of a breathing disability or chronic cough during service. Indeed, the first mention of any actual breathing issues was not documented until 2006, and again in 2013 many years after separation, when the Veteran first reports a persistent cough. The granulomas identified in 1990 were nonspecific in nature, and found to be old histoplasmosis in 2006. There are multiple possible morbidities to explain such a diagnosis. Further, the granulomas found in 1990 were considered calcified by 1999, and again in 2006 and 2020. The Board finds these opinions to be persuasive. They were rendered by a medical specialist in contemplation of the complete medical record and medical history reported by the Veteran. They applied the facts of this specific case to known medical principles, and supported the conclusion with a detailed discussion. The Board recognizes the Veteran's firmly held belief that his present bronchitis is related to active service, but finds this of limited probative value. While lay evidence may be competent on a variety of matters concerning the nature and cause of disability, etiology of dysfunctions and disorders is a medical determination and generally must be established by medical findings and opinion. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Colantonio v. Shinseki, 606 F.3d 1378, 1382 (Fed.Cir.2010) (recognizing that in some cases lay testimony "falls short" in proving an issue that requires expert medical knowledge). In the present case, the Veteran is a lay person without appropriate medical training and expertise, and thus, is not competent to make an etiological conclusion regarding the cause of his respiratory disability, especially in light of the VA specialists' conclusions to the contrary and the fact that the evidence fails to demonstrate the onset of any bronchial, pulmonary, or respiratory disability or any other breathing-related complaints until many years after separation from service. See id. In sum, the Board finds that the Veteran's present respiratory diagnoses are less likely than not related to any incident of active service, particularly his service at Camp LeJeune. As such, the claim fails the third prong of service connection, and it must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, because the preponderance of the evidence is against the claim, that doctrine does not apply. See 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. 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. Pryce, Counsel