Citation Nr: 21076382 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 18-46 221A DATE: December 23, 2021 ORDER The claim of entitlement to a disability rating greater than 30 percent for service-connected migraine headaches is dismissed. Service connection for diabetes mellitus is denied. Service connection for peripheral neuropathy of bilateral upper extremity is denied. Service connection for peripheral neuropathy of bilateral lower extremity is denied. Service connection for sleep apnea is denied. Service connection for residuals of breast cancer is denied. Service connection for residuals of cholecystectomy is denied. Service connection for right knee disability, to include degenerative changes, is denied. Service connection for left knee disability, to include degenerative changes, is denied. Service connection for residuals of left foot injury is granted. Service connection for radiculopathy of bilateral upper extremity is denied. Service connection for radiculopathy of bilateral lower extremity is denied. Service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression, is granted. Service connection for traumatic brain injury, with residuals, is denied. Service connection for a disability manifested by memory loss is denied. Service connection for chronic fatigue syndrome is denied. Service connection for tinnitus is granted. Service connection for purposes of receiving compensation for tooth loss is denied. Service connection for a temporomandibular joint disorder is denied. REMANDED Entitlement to service connection for cervical spine disability is remanded. Entitlement to service connection for disabilities of right shoulder is remanded. Entitlement to service connection for disabilities of left shoulder is remanded. FINDINGS OF FACT 1. In October 2018, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that the appeal for a disability rating greater than 30 percent for service-connected migraine headaches was withdrawn. 2. The Veteran's diabetes mellitus was not manifest during active service or within the first year after service, and is not otherwise shown to be related to service. 3. The Veteran's peripheral neuropathy of bilateral upper extremities was not manifest during active service or within the first year after service, and is not otherwise shown to be related to service or to service-connected disease or injury. 4. The Veteran's peripheral neuropathy of bilateral lower extremities was not manifest during active service or within the first year after service, and is not otherwise shown to be related to service or to service-connected disease or injury. 5. The Veteran's sleep apnea was not manifest during active service, and is not otherwise shown to be related to service or to service-connected disease or injury. 6. The Veteran's residuals of breast cancer were not manifest during active service, and are not otherwise shown to be related to service or to service-connected disease or injury; and malignant tumors of breast tissue were not manifest in service or within the first year after service. 7. The Veteran's residuals of cholecystectomy were not manifest during active service, and are not otherwise shown to be related to service; and calculi of the gallbladder were not manifest in service or within the first year after service. 8. The Veteran's right knee disability, to include degenerative changes, was not manifest during active service or within the first year after service; and is not attributable to service. 9. The Veteran's left knee disability, to include degenerative changes, was not manifest during active service or within the first year after service; and is not attributable to service. 10. The Veteran's residuals of left foot injury, manifested by pain causing functional impairment, are attributable to service. 11. The Veteran has not been diagnosed with radiculopathy of bilateral upper extremity. 12. The Veteran has not been diagnosed with radiculopathy of bilateral lower extremity. 13. The occurrence of a sexual assault during active service has been established by medical opinions based on a review of the evidence; and currently diagnosed PTSD, to include depression, is related to such assault. 14. A head injury in active service was acute and resolved without residuals; the Veteran has not been diagnosed with traumatic brain injury, including residuals, at any time during the appeal period. 15. There is no diagnosed disability manifested as memory loss. 16. The Veteran has not been diagnosed with chronic fatigue syndrome at any time during the appeal period. 17. Currently diagnosed tinnitus had its onset during active service. 18. The Veteran's in-service dental treatment was due to causes other than a combat wound or trauma. 19. The Veteran's temporomandibular joint was not manifest during active service and is not attributable to service or to service-connected disease or injury. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the claim of entitlement to a disability rating greater than 30 percent for service-connected migraine headaches, by the Veteran have been met. 38 U.S.C. § 7105(b)(2), (d)(5); 38 C.F.R. § 19.55. 2. The criteria for service connection of diabetes mellitus are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309. 3. Peripheral neuropathy of bilateral upper extremity, to include as due to or a result of service-connected disease or injury, was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310. 4. Peripheral neuropathy of bilateral lower extremity, to include as due to or a result of service-connected disease or injury, was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310. 5. Sleep apnea, to include as due to or a result of service-connected disease or injury, was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 6. Residuals of breast cancer, to include as due to or a result of service-connected disease or injury, were not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310. 7. Residuals of cholecystectomy were not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309. 8. Right knee disability, to include degenerative changes, was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309. 9. Left knee disability, to include degenerative changes, was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309. 10. Residuals of left foot injury were incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 11. Radiculopathy of bilateral upper extremity, to include as due to or a result of service-connected disease or injury, was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310. 12. Radiculopathy of bilateral lower extremity, to include as due to or a result of service-connected disease or injury, was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.309, 3.310. 13. PTSD was incurred in peacetime service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 14. Traumatic brain injury, with residuals, was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 15. Chronic fatigue syndrome was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. 16. Tinnitus was incurred in peacetime service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 17. The claim of entitlement to service connection for tooth loss, for purposes of receiving compensation, is without legal merit. 38 U.S.C. §§ 1131, 1712; 38 C.F.R. §§ 3.381, 17.161. 18. A temporomandibular joint disorder was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from June 1977 to April 1979. She timely appealed these matters to the Board of Veterans' Appeals (Board) from August 2017 and January 2018 rating decisions by the Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). VA is obliged to provide an examination when the record contains competent evidence that the claimant has a current disability or signs and symptoms of a current disability, the record indicates that the disability or signs and symptoms of disability may be associated with active service; and the record does not contain sufficient information to make a decision on the claim. 38 U.S.C. § 5103A(d). The evidence of a link between current disability and service must be competent. Wells v. Principi, 326 F.3d 1381 (Fed. Cir. 2003). For certain claims decided belownamely, those alleged as due to exposure in active service to herbicides, chemicals, and toxinsthere is neither evidence of pertinent disability in active service, nor competent medical evidence suggesting a relationship between current disabilities and active service. Based solely on these facts, VA has no duty to provide further VA examination or obtain medical opinions, even under the low threshold of McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). All available records identified by the Veteran as relating to claims decided below were obtained, to the extent possible. The record does not otherwise indicate any existing pertinent evidence that has not been obtained. Examination reports and opinions are thorough and adequate for the Board to render the following decisions in the Veteran's appeal. 38 U.S.C. § 5103A(a)(2). DISMISSAL The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the Veteran or by her authorized representative. 38 C.F.R. § 19.55. Via an October 2018 telephone call, the Veteran accepted the award of a 30 percent disability evaluation for migraine headaches; and withdrew her appeal for an evaluation of migraine headaches in excess of 30 percent disabling. The withdrawal is reduced to writing on VA Form 27-0820. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the appeal with regard to that issue, and it is dismissed. SERVICE CONNECTION Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection on a direct basis, the record must contain competent evidence of: (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 (Fed. Cir. 2004). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability that are subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Some chronic diseasessuch as malignant tumors, calculi of gallbladder, tinnitus (as an organic disease of the nervous system), and arthritismay be presumed to have been incurred in service, if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). 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). The applicable presumptive period is generally one year from separation. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. When service connection is established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). In this case, the Veteran was presumed sound at service entry. Clinical evaluation at entry in December 1976 was normal, and no disability was recorded. Nor is there medical evidence of any disability prior to active service. The Board is within its province to make a determination as to whether the evidence supports a finding of service incurrence. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Here, the Veteran contends that certain claimed disabilities resulted from exposure to herbicides, chemicals, and toxins while stationed at Fort McClellan in active service. Her service personnel records show that she was stationed at Fort McClellan from June 7, 1977, to August 3, 1977. Specifically, the Veteran stated that she was exposed to polychlorinated biphenyls (PCB's), trichloroethylene (TCE), and herbicides (Agent Orange and Agent White) because a civilian company dumped toxic waste into the soil and water supply; and that Fort McClellan is one of the most toxic sites in the United States. Radiation levels exceeded acceptable limits. Fort McClellan is adjacent to the town of Anniston, Alabama, which settled with the civilian company. An April 2018 response from the Defense Personnel Records Information Retrieval System (DPRIS) indicates that the service department was unable to locate any unit records from 1977 of Company B, 2nd Basic Training Battalion, Fort McClellan, Alabama. Due to the lack of unit records, the service department was unable to document the Veteran's exposure to tactical herbicides, including Agent Orange, at Fort McClellan. In May 2018, the Department of Defense (DOD) provided a listing of locations outside Vietnam and outside the Korean demilitarized zone (DMZ) where Agent Orange was used, tested, and stored. The listing shows no names of individuals involved with Agent Orange. There are no references to routine base maintenance activities such as range management, brush clearing, and weed killingeach of which was accomplished with commercial herbicides on all military bases worldwide. No commercial herbicides are governed by regulations pertaining to Agent Orange exposure in active service. Moreover, DOD has not identified Fort McClellan as a location where Agent Orange was used, tested, or stored. There is no evidence associating Agent Orange with the U.S. Army Chemical School (ACS) or Chemical-Biological-Radiological (CBR) Agency located at Fort McClellan. Agent Orange was developed for combat operations in Vietnam and was used in Vietnam from 1962 to early 1971. There were no combat operations at Fort McClellan during those years and no need for use of Agent Orange at Fort McClellan. Additionally, Fort McClellan was not on the Agent Orange shipping supply line, which went directly from Gulfport, Mississippi, to South Vietnam via merchant ships. Regarding other claimed chemical exposures, VA has no evidence of such exposures or evidence of long-term health effects associated with any such exposures. In August 2018, the Armed Forces Pest Management Board (AFPMB) confirmed that DOD engaged in thorough searches of its and other federal agencies' records over the years relating to Agent Orange and other tactical herbicides. Discovered records indicate that Agent Orange and other tactical herbicides were never used or tested at, disposed of, transported through, or stored on Fort McClellan. In September 2018, the AFPMB noted that "live agents and toxins" are not under its purview. In November 2018, VA received DOD's "Achieving Response Complete at Installation Restoration Program Sites" report, dated in January 2018. The report identified buildings and areas at Fort McClellan which may have been associated with the use, storage, handling, disposal, or burial of radioactive materials; or, contained information supporting unrestricted site release. According to DOD's report, the ACS was located at Fort McClellan from 1951 to 1973 and from 1979 to 1999. From 1957 to 1972, Fort McClellan was authorized and licensed to use radioactive material; the licenses were terminated when ACS relocated to Aberdeen, Maryland, in 1973. At the time there was residual cobalt 60 and cesium 137 contamination in the hot cell in Building 3192 and surrounding ground contamination from an associated underground holding tank. ACS closed the radiological facilities in 1972 and removed all radioactive sources from Fort McClellan. ACS was deactivated in 1973; at that time, Building 3182 was turned into a Military Police Museum. Remediation at Building 3192 and surrounding areas started in 1985, and underground tanks were removed. Building 3180 was demolished in 1989. The Board notes that the reactivation of ACS at Fort McClellan in 1979 occurred after the time period when the Veteran was stationed at Fort McClellan. All additional remediation and restoration efforts occurring in subsequent years at Fort McClellan are not pertinent to the Veteran's claims. VA has recognized the possibility of exposures to chemicals as a result of emissions from the privately owned chemical plant nearby Fort McClellan. See https://www.publichealth.va.gov/exposures/fort-mcclellan/; Euzebio v. McDonough, 989 F.3d 1305 (Fed. Cir. 2021). However, such threat was from airborne particles, and the plant shut down in 1971, prior to the Veteran's duty there. Moreover, subsequent studies have shown no adverse health conditions or increased risks for cancer or other harmful effects in connection with the area around the plant. Here, the AOJ attempted to corroborate the Veteran's allegations of significant exposure to herbicides, chemicals, and toxins while stationed at Fort McClellan during active service. Based on the evidence of record, the Board finds no credible evidence of significant exposure while the Veteran was stationed at Fort McClellan from June 7, 1977, to August 3, 1977. For purposes of service connection, an in-service injury or disease is not established for certain claimed disabilities based on allegations of exposures in active service. Diabetes Mellitus Service treatment records do not show any signs or symptoms of diabetes mellitus or complaints of endocrine problems. There is no evidence of treatment in active service for diabetes mellitus. On a report of medical history completed by the Veteran at her discharge examination from active service in April 1979, she checked "no" in response to whether she ever had or now had sugar or albumin in urine. Laboratory findings included urinalysis in April 1979, which was negative for albumin and sugar. Here, the evidence does not show that diabetes mellitus had its onset in active service. As noted above, an in-service injury or disease based on alleged exposures to herbicides, chemicals, and toxins while stationed at Fort McClellan during active service has not been established. Therefore, the in-service element has not been met. Private records, dated in August 2013, show an assessment of uncontrolled diabetes mellitus. In January 2017, the Veteran's treating physician submitted a Disability Benefits Questionnaire (DBQ), indicating that the Veteran was diagnosed with diabetes mellitus; and that the date of diagnosis was April 2008. The Veteran had progressive loss of strength attributable to diabetes mellitus; the grip of her right hand was weak. Complications included diabetic peripheral neuropathy and mild proteinuria. There were no other significant findings. Diabetes mellitus did not impact the Veteran's ability to work. In January 2017, the Veteran's treating physician indicated that it came to [the physician's] attention that the Veteran was exposed to Agent Orange, PCB's, herbicides, nerve agents, radioisotopes, cesium, and sulfur mustard. The treating physician opined that such exposures while at Fort McClellan were at least as likely, if not more likely, the cause of [the Veteran's] "myriad of medical maladies." In support of the opinion, the treating physician reasoned that it had been proven that carcinogenic, chemical, and ionizing radiation exposures can induce the development of such diseases. The Veteran underwent a VA examination in January 2020. The examiner noted a diagnosis of diabetes mellitus; the date of diagnosis was October 2008. Insulin was required for treatment. No complications of diabetes mellitus were reported. There were no other pertinent physical findings. Diabetes mellitus did not impact the Veteran's ability to work. Following examination, the January 2020 examiner opined that diabetes mellitus was less likely than not incurred in or caused by claimed exposure to PCB's at Fort McClellan. In support of the opinion, the examiner reasoned that there was not enough available evidence to establish a connection between diabetes mellitus and exposure to PCB's during active service. A nexus has not been established. As noted above, the Veteran's treating physician's opinion that the Veteran's "myriad of medical maladies" is more likely caused by exposures at Fort McClellan, is speculative in nature and based solely on possibility; and, thus, has no probative value. Additionally, the evidence of record indicates that the fact of exposure is questionable, at best. While the Veteran is competent to describe symptoms, the evidence does not reveal signs or symptoms of diabetes mellitus in active service; onset in active service has not been demonstrated. Moreover, the concept of continuity does not apply because there is no showing of diabetes mellitus until decades after active service. Walker, 708 F.3d at 1338-39. Further, a causal link between alleged in-service exposures and diabetes mellitus has not been established. Hence, the nexus element has not been met. In short, the preponderance of the evidence is against granting service connection for diabetes mellitus. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Peripheral Neuropathy of Upper and Lower Extremities Service treatment records do not show any signs or symptoms of peripheral neuropathy or complaints of numbness or tingling of upper and lower extremities. There is no evidence of treatment in active service for peripheral neuropathy. On a report of medical history completed by the Veteran at her discharge examination from active service in April 1979, she checked "no" in response to whether she ever had or now had neuritis or paralysis. Here, the evidence does not show that peripheral neuropathy of upper and lower extremities had its onset in active service. As noted above, an in-service injury or disease based on alleged exposures to herbicides, chemicals, and toxins while stationed at Fort McClellan during active service has not been established. Therefore, the in-service element has not been met. Social Security records, dated in February 2012, reveal that the Veteran had been diagnosed with peripheral diabetic neuropathy of bilateral lower extremity and right elbow to wrist in April 2008. The Veteran was not referred to a specialist, which indicated that the condition generally was controlled with pain medications. In January 2017, the Veteran's treating physician submitted a DBQ, indicating that the Veteran was diagnosed with peripheral neuropathy; and that the date of diagnosis was April 2008. Symptoms included moderate intermittent pain and paresthesias of right upper extremity, and mild intermittent pain and paresthesias of bilateral lower extremity. There was no muscle atrophy or trophic changes. Affected nerves were identified. Pertinent physical findings included tingling and prickling of right hand and bilateral foot, as well as some pain and cramping. Typing with right hand and standing for prolonged periods were difficult. In January 2017, the Veteran's treating physician indicated that it came to [the physician's] attention that the Veteran was exposed to Agent Orange, PCB's, herbicides, nerve agents, radioisotopes, cesium, and sulfur mustard. The treating physician opined that such exposures while at Fort McClellan were at least as likely, if not more likely, the cause of [the Veteran's] "myriad of medical maladies." In support of the opinion, the treating physician reasoned that it had been proven that carcinogenic, chemical, and ionizing radiation exposures can induce the development of such diseases. The Veteran underwent a VA examination in October 2017. Affected nerves were identified. Following examination, the October 2017 examiner opined that there was mild peripheral neuropathy of bilateral lower extremity, which was at least as likely as not related to diabetes mellitus. Here again, the Veteran's treating physician's opinion that the Veteran's "myriad of medical maladies" is more likely caused by exposures at Fort McClellan, is speculative in nature and based solely on possibility; and, thus, has no probative value. Actual exposure is also questionable. While the Veteran is competent to describe symptoms, the evidence does not reveal signs or symptoms of peripheral neuropathy in active service; onset in active service has not been demonstrated. Moreover, the concept of continuity does not apply because there is no showing of peripheral neuropathy of upper and lower extremities until decades after active service. Walker, 708 F.3d at 1338-39. Further, a causal link between alleged in-service exposures and peripheral neuropathy has not been established. Again, the nexus element has not been met. The evidence is also against a finding that peripheral neuropathy of upper and lower extremities is related to a service-connected disease or injury. Significantly, as shown above, service connection has not been established for diabetes mellitus. In short, the preponderance of the evidence is against granting service connection for peripheral neuropathy of upper and lower extremities. On these matters, the benefit-of-the-doubt rule does not apply, and the claims must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Sleep Apnea Service treatment records do not show any signs or symptoms of sleep apnea or complaints of excessive daytime sleepiness. There is no evidence of treatment in active service for sleep apnea. Here, the evidence does not show that sleep apnea had its onset in active service. As noted above, an in-service injury or disease based on alleged exposures to herbicides, chemicals, and toxins while stationed at Fort McClellan during active service has not been established. Therefore, the in-service element has not been met. Social Security records, dated in February 2012, reveal that the Veteran had been using a CPAP machine since at least July 2008, although there are no complaints related to sleep apnea. No functional limitations were noted. Private records show an assessment of possible underlying sleep apnea in August 2013. In January 2017, the Veteran's treating physician indicated that it came to his attention that the Veteran was exposed to Agent Orange, PCB's, herbicides, nerve agents, radioisotopes, cesium, and sulfur mustard. The treating physician opined that such exposures at Fort McClellan were at least as likely, if not more likely, the cause of [the Veteran's] "myriad of medical maladies." In support of the opinion, the treating physician reasoned that it had been proven that carcinogenic, chemical, and ionizing radiation exposures can induce the development of such diseases. The Veteran underwent a consultation for obstructive sleep apnea in February 2017. She reported being diagnosed with sleep apnea over ten years ago and reported using CPAP for a short period of time. She now experienced morning headaches, fatigue, and overall feeling tired throughout the day. A home sleep test showed mild obstructive sleep apnea. A new CPAP machine was ordered. In January 2020, the Veteran's treating physician opined that the Veteran's sleep apnea was related to obesity, which was related to diabetes mellitus. As noted above, the Veteran's treating physician's opinion that the Veteran's "myriad of medical maladies" is more likely caused by exposures at Fort McClellan, is speculative in nature and based solely on possibility; and, thus, has no probative value. Additionally, the fact of exposure is questionable. While the Veteran is competent to describe symptoms, the evidence does not reveal signs or symptoms of sleep apnea in active service; onset in active service has not been demonstrated. Further, a causal link between alleged in-service exposures and sleep apnea has not been established. Again, the nexus element has not been met. The evidence is also against a finding that sleep apnea is related to a service-connected disease or injury. Significantly, service connection has been established for neither diabetes mellitus nor obesity. In short, the preponderance of the evidence is against granting service connection for sleep apnea. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Residuals of Breast Cancer Service treatment records do not show any signs or symptoms of breast cancer or complaints of residuals. Nor is there evidence of breast tumors in active service. There is no evidence of treatment in active service for breast cancer. Clinical evaluation of lungs and chest, including breasts, was normal, and chest X-rays were within normal limits at the Veteran's separation examination from active service in April 1979. Here, the evidence does not show that residuals of breast cancer had their onset in active service. As noted above, an in-service injury or disease based on alleged exposures to herbicides, chemicals, and toxins while stationed at Fort McClellan during active service has not been established. Therefore, the in-service element has not been met. Rather, Social Security records reflect that the Veteran's disability began in February 2012; the primary diagnosis was malignant neoplasm of uterus, and the secondary diagnosis was malignant neoplasm of breast. For purposes of Social Security benefits, the Veteran was not considered disabled in February 2012. In January 2017, the Veteran's treating physician submitted a DBQ, indicating that the Veteran first was diagnosed with left lobular carcinoma in-situ in October 2013; and that she underwent a breast reduction in February 2014. Neither residual conditions nor pertinent physical findings were indicated; scars were noted. There was no recurrence of breast cancer. Residuals of breast cancer did not impact the Veteran's ability to work. In January 2017, the Veteran's treating physician indicated that it came to [the physician's] attention that the Veteran was exposed to Agent Orange, PCB's, herbicides, nerve agents, radioisotopes, cesium, and sulfur mustard. Given such exposures, the treating physician opined that they were at least as likely, if not more likely, the cause of [the Veteran's] "myriad of medical maladies." In support of the opinion, the treating physician reasoned that it had been proven that carcinogenic, chemical, and ionizing radiation exposures can induce the development of such diseases. While the Veteran is competent to report what she was told by a physician, the Board finds the Veteran's treating physician's opinion that the Veteran's "myriad of medical maladies" is more likely caused by exposures at Fort McClellan, to be speculative in nature and based solely on possibility. Hence, the opinion has no probative value; additionally, actual exposure is not established to support such an opinion. While the Veteran is competent to describe symptoms, the evidence does not reveal any signs or symptoms of breast cancer in active service; onset in active service has not been demonstrated. Moreover, the concept of continuity does not apply because there is no showing of any malignant tumor until decades after active service. Walker, 708 F.3d at 1338-39. Further, a causal link between alleged in-service exposures and residuals of breast cancer has not been established. Therefore, the nexus element has not been met. In January 2020, the Veteran's treating physician opined that the Veteran's breast cancer was related to obesity, which was the consequence of diabetes mellitus, metabolic derangement, and the pro-inflammatory effects of hyperinsulinemia. No rationale was provided. The evidence is also against a finding that residuals of breast cancer are related to a service-connected disease or injury. Significantly, as shown above, service connection has not been established for diabetes mellitus. In short, the preponderance of the evidence is against granting service connection residuals of breast cancer. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Residuals of Cholecystectomy Service treatment records do not show any signs or symptoms of gallbladder problems or complaints. Nor is there evidence of surgical removal of gallbladder in active service. There is no evidence of treatment in active service for gallbladder problems or jaundice. On a report of medical history completed by the Veteran at her discharge examination from active service in April 1979, she checked "no" in response to whether she ever had or now had gallbladder trouble or gallstones or jaundice or hepatitis. Here, the evidence does not show that residuals of cholecystectomy had their onset in active service. As noted above, an in-service injury or disease based on alleged exposures to herbicides, chemicals, and toxins while stationed at Fort McClellan during active service has not been established. Therefore, the in-service element has not been met. In January 2017, the Veteran's treating physician submitted a DBQ, indicating that the Veteran was diagnosed with cholecystectomy, biliary dyskinesia, and dyspepsia; and that abdominal pain preceded findings of biliary dyskinesia with cholecystitis requiring removal. The Veteran had four or more gallbladder disease-induced dyspepsia and no attacks of gallbladder colic. Dyspepsia and scars were noted. There were no other significant findings. Residuals of cholecystectomy did not impact the Veteran's ability to work. In January 2017, the Veteran's treating physician indicated that it came to [the physician's] attention that the Veteran was exposed to Agent Orange, PCB's, herbicides, nerve agents, radioisotopes, cesium, and sulfur mustard. The treating physician opined that such exposures while at Fort McClellan were at least as likely, if not more likely, the cause of [the Veteran's] "myriad of medical maladies." In support of the opinion, the treating physician reasoned that it had been proven that carcinogenic, chemical, and ionizing radiation exposures can induce the development of such diseases. The Board finds the Veteran's treating physician's opinion that the Veteran's "myriad of medical maladies" is more likely caused by exposures at Fort McClellan, to be speculative in nature and based solely on possibility. Hence, the opinion has no probative value. As is noted above, the alleged exposures themselves are questionable. While the Veteran is competent to describe symptoms, the evidence does not reveal any residuals of cholecystectomy in active service; onset in active service has not been demonstrated. Moreover, the concept of continuity does not apply because there is no showing of gallstones or disease requiring removal of gallbladder until decades after active service. Walker, 708 F.3d at 1338-39. Further, a causal link between alleged in-service exposures and residuals of cholecystectomy has not been established. Therefore, the nexus element has not been met. In short, the preponderance of the evidence is against granting service connection for residuals of cholecystectomy. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Right Knee and Left Knee Disabilities Service treatment records do not reflect any findings or complaints of knee problems or trauma to either knee. There is no evidence of treatment in active service for disabilities of either knee. Arthritis of each knee was not demonstrated in active service or within the first post-service year. An in-service injury or disease based on alleged exposures to herbicides, chemicals, and toxins while stationed at Fort McClellan during active service has not been established. Therefore, the in-service element has not been met. Rather, post-service records, dated in June 2015, show injury or onset of knee disabilities in June 2004. The Veteran underwent a left total knee replacement in 2004. MRI scans revealed osteoarthritic changes and tear of anterior cruciate ligament of right knee in October 2008, and the Veteran underwent a right total knee replacement in November 2008. During a June 2016 VA examination, the Veteran reported symptoms of right knee pain with sit-to-stand and pain with kneeling; she was unable to get up out of tub, and unable to stay in any one position for more than five minutes. Examination in June 2016 revealed instability of each knee. Ranges of motion were decreased on flexion; there was pain on motion. There was no history of knee trauma. In this case, there is a gap of decades between the Veteran's separation from active service in April 1979 and records documenting disability of each knee. The evidence does not reveal any knee disability during active service, or that arthritis of each knee manifested within one year after the Veteran's separation from active service. As such, she is not entitled to direct or presumptive service connection. While the Veteran is competent to describe her symptoms, here, the evidence does not reveal any knee problems or injury in active service. The Veteran specifically denied any arthritis, rheumatism, or bursitis; and denied any bone, joint, or other deformity in active service. Even assuming the Veteran was treated for recurrent knee pain at times, there is no evidence of chronicity of care following active service. Degenerative changes of each knee first were noted decades after service. An alternative route to direct service connection for arthritis of each knee is not demonstrated. Walker, 708 F.3d at 1338-39. The objective evidence does not support a finding of service incurrence. Barr, 21 Vet. App. at 307. No examiner has associated the Veteran's current disabilities of each knee, to include degenerative changes, with active service. The Board concludes that the preponderance of the evidence is against granting service connection. On these matters, the benefit-of-the-doubt rule does not apply, and the claims must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Residuals of Left Foot Injury Service treatment records show that the Veteran experienced a click in her left foot for three days while running during basic training in July 1977. She reported pain with weight on ball of foot. X-rays taken at the time were negative; physical therapy followed. In September 1977, the Veteran was diagnosed with tendonitis dorsal of first and second toes of left foot; her profile was limited temporarily for running. X-rays taken in September 1977 revealed no significant abnormality of left foot. In April 1979, the Veteran specifically denied foot trouble on a report of medical history completed contemporaneously with her separation examination. Physical examination in April 1979 revealed no defects. Post-service records, dated in September 2017, reveal that the Veteran reported constant pain in left foot since the injury in service. An October 2017 VA examination report reveals a diagnosis of left foot pain and injury. The Veteran reported a history of "hearing a snap" in left foot in basic training. She reported having intermittent left foot pain since 2002, especially with prolonged standing and walking and running. No major incapacitating episodes or flare-ups were reported. Functional impairment consisted of pain in left foot with prolonged weight-bearing, standing, and walking. Diagnostic testing revealed no degenerative or traumatic arthritis of left foot. The October 2017 examiner opined that the Veteran's left foot condition is at least as likely as not incurred in or caused by the injury during active service. While no residuals were shown on examination, the examiner reasoned that a left foot injury is documented in service treatment records. Given the nature of the Veteran's intermittent left foot pain, her credible lay statements of in-service injury and recurring symptoms following discharge from service, as well as evidence of current functional impairment consisting of pain in left foot, the Board finds that the Veteran's residuals of left foot injury had their onset in active service. Service connection for residuals of left foot injury is, therefore, warranted. Radiculopathy of Upper and Lower Extremities Service treatment records do not reflect any findings or complaints of radiculopathy. The Veteran underwent no treatment for radiculopathy of each upper and lower extremity in active service. Physical examination at separation from active service in April 1979 revealed no defects. VA examinations in May 2017 revealed neither findings of radicular pain, nor signs nor symptoms due to radiculopathy of each upper and lower extremity. Both sensory examinations and reflex examinations were normal. There were no findings of intervertebral disc syndrome of either cervical spine or thoracolumbar spine, and no incapacitating episodes were reported. No examiner has found objective evidence or pathology which would support diagnoses of radiculopathy of bilateral upper extremity and radiculopathy of bilateral lower extremity. The Board has considered the Veteran's statements regarding radiculopathy of each extremity as due to her service-connected degenerative disc disease of lumbar spine, or as involving her cervical spine disability. However, there are no formal diagnoses of any radiculopathy, despite repeated testing and examination to explain her subjective complaints and observed symptoms. At worst, an October 2017 VA examination report reveals that the Veteran's bilateral lower extremity symptoms were primarily those of mild peripheral neuropathy related to diabetes mellitus; such matter is addressed above. In the absence of proof of present radiculopathy of bilateral upper extremity and radiculopathy of bilateral lower extremity, there can be no valid claims. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Acquired psychiatric disorder, to include PTSD and depression The Veteran's mental health claim has been recharacterized to reflect all potentially diagnosed psychiatric disorders. Clemons v. Shinseki, 23 Vet. App. 1 (2009). The evidence, discussed below, indicates some disagreement over the appropriate label for the variously diagnosed mental condition, though PTSD appears to be predominant. The Veteran clarified in February 2017 that she was forced to have non-consensual sex with another servicemember while stationed at Fort Sam Houston in Texas in 1977. She reported the incident but stated that nothing was done about it. She was stationed at Fort Sam Houston from August 1977 to October 1977. The Veteran is competent to report what occurred in service because her statements regard her first-hand knowledge of a factual matter. Here, a June 2017 VA examiner, who is a psychologist, found that the Veteran's symptoms did meet diagnostic criteria for PTSD under DSM-5. The Veteran experienced high levels of anxiety and experienced flashbacks and dreams about being sexually assaulted. She lacked trust in people and avoided forming new relationships. She had a quick startle reaction when anyone touched her, and she tended to withdraw and isolate from others. The June 2017 VA examiner also noted social behavioral changes in that the Veteran stopped going out, dropped her interest and activities, and just stayed and read in her room. She experienced episodes of anxiety and depression, and experienced periods of overeating and undereating. Current symptoms included depressed mood, anxiety, suspiciousness, panic attacks, chronic sleep impairment, impairment of short-term and long-term memory, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty in adapting to stressful circumstances, impaired impulse control, and intermittent inability to perform activities of daily living. The June 2017 VA examiner opined that the Veteran's PTSD is at least as likely as not caused by or a result of in-service MST (military sexual trauma)-related markers. In September 2017, the Veteran reported having trouble remembering the exact dates of when events took place in active service. She indicated that the sexual assault occurred around August 1977. She explained that the rape was by another servicemember who also was going through training to be an operating room technician. The Veteran did talk to the head captain about this, and was told not to tell anyone because it would cause trouble. The Veteran underwent another examination in December 2017. Her personal psychological history prior to active service was not significant. She reported participating in psychotherapy during and after her divorce due to depression, and to address childhood sexual abuse issues. The Veteran reportedly struggled with depression since her separation from active service due to "not fitting in" and "low self-esteem." She reported being diagnosed with PTSD, and being attacked and raped during training in Texas (after basic training). Her Sergeant told her not to make the report official because it would be a "bad mark" on her record. The December 2017 examiner found that the Veteran's symptoms currently did not meet criteria for a diagnosis of PTSD. A November 2019 VA examination report revealed a diagnosis of PTSD that conforms to DSM-5 criteria. Her military history reflects that she had gotten along well with the troops and the brass until after her rape in 1977, when she started losing her concentration and sleeping all the time. Her military occupational specialty was change due to such poor performancethat is, from being a surgical technician in the operating room to changing oil and pushing trucks in the motor pool. The Veteran had married while on base during her last year at her next duty station at Fort Leonard Wood; her husband later divorced her in 2016, complaining that the Veteran did not meet his sexual needs. The Veteran also stopped driving more than 10 miles or taking any expressways due to her fear of getting lost and having to ask for help. She had trouble trusting any males. Following examination, the November 2019 examiner opined that PTSD was at least as likely as not incurred in or caused by the in-service MST. In support of the opinion, the examiner reasoned that the Veteran demonstrated symptoms of intrusive memories, avoidance of memories, numbing negativism, and hyperarousalall related to the MSTdespite extended psychiatric treatment. The Board finds the November 2019 VA examiner's opinion persuasive. Notably, the Veteran's statements support this determination. The November 2019 examiner found that current PTSD symptoms meet DSM-5 criteria. In December 2019, an independent medical reviewer, who is a psychologist, noted behavioral changes, including the Veteran's reporting the incident to another trainee; the Veteran's having trouble with concentration and crying all the time; the Veteran's drinking a six pack at the local PX several times a week; the Veteran's losing her operating room technician job due to performance; and the Veteran's having trouble trusting any males. Where, as here, a PTSD claim is based on an in-service personal assault, evidence from sources other than the Veteran's service records may corroborate the Veteran's account of the stressor incident. Examples of potentially useful evidence may include records from law enforcement, rape crisis centers, mental health counseling centers, hospitals, statements from family members, roommates, clergy, or other similar sources. Evidence of behavior changes following the claimed assault is also one type of relevant evidence that may be found from these sources. 38 C.F.R. § 3.304 (f)(5). It is also important to note that for personal assault PTSD claims, an after-the-fact medical opinion may serve as the credible supporting evidence of the reported stressor. Patton v. West, 12 Vet. App. 272, 280 (1999). The Board finds the Veteran's statements credible. The totality of the evidence, including behavioral changes since service and the consistency of reports, supports such finding. Therefore, the diagnosis of PTSD is based on a valid in-service stressor, and the opinions of the June 2017 and November 2019 examiners relating current PTSD symptoms to the in-service stressor are considered highly probative. There are no negative nexus opinions. The weight of the evidence accordingly favors the claim, and service connection for an acquired psychiatric disorder, to include PTSD and depression, is warranted. Traumatic Brain Injury In September 2021, the Veteran clarified that a traumatic brain injury was due to in-service injury. Specifically, she sustained a significant blow to the head in active service and noted the possibility of a mild traumatic brain injury. The Veteran also contended that she struck the back of her head when she fell on ice while working under a truck in active service in January 1979. She is competent to testify on factual matters of which she has first-hand knowledge. Washington v. Nicholson, 19 Vet. App. 362 (2005). Service treatment records reflect that the Veteran was struck with a softball in June 1978. She complained of headaches; the assessment was ecchymosis of right orbit. Facial series of X-rays at the time were negative. The Veteran also fell on ice in January 1979; X-rays at the time were taken of her dorsal and cervical spine and right shoulder. She specifically denied head injury on a report of medical history completed contemporaneously with her separation examination in April 1979. The Veteran underwent an examination in December 2017. The examiner, who is a physiatrist, indicated that the Veteran did have a diagnosis of traumatic brain injury; the date of diagnosis was June 1998. She had another diagnosis of headaches, and the date of diagnosis was June 2019. Specific history for traumatic brain injury reflects the onset of symptoms was 1979. The Veteran's head was struck by a softball. She also struck the back of her head when she tried to get up from working under a truck in January 1979. The Veteran complained of losing track of what she was thinking in the middle of conversation, and reportedly forgot appointments all the time and required notes for reminders. She also occasionally made inappropriate statements, had less empathy, and preferred to stay home. The Veteran had to look at her watch to tell the time of day, and she easily became disoriented in unfamiliar situations and became nervous. She reportedly missed an event due to a severe headache, and she sometimes forgot her meals due to headaches. The Veteran also reported that at times people did not understand what she was communicating to them. The December 2017 examiner noted that the Veteran's service-connected migraine headaches have not been attributed to traumatic brain injury. There are no other pertinent physical findings, complications, conditions, signs, or symptoms. Neuropsychological testing had not been performed. There was no functional impact attributable to traumatic brain injury. The examiner opined that there was no current diagnosis of traumatic brain injury, with residuals, because the condition had resolved. A screening for cognitive impairment was conducted in December 2017. The Veteran's testing score was just below normal; no significant dysfunction was noted. The Veteran's complaints were simply headaches and memory loss, and she was unable to describe memory issues. Treatment in recent years for major depressive disorder and for generalized anxiety disorder was in relation to marital strife and divorce. No psychiatric disability was noted as a residual of traumatic brain injury. In May 2018, the Veteran's treating physician noted the Veteran's numerous injuries to head and neck in active service; and opined that, with the loss of consciousness, the Veteran may indeed have sustained a traumatic brain injury. In support of the opinion, the treating physician referenced "medical literature" that it was undeniable that the military shared risks of bodily harm and manifestations of such injuries later in life. Significantly, the treating physician did not diagnose a current traumatic brain injury; thus, the opinion has minimal probative value. Recent VA treatment records consistently show no findings or residuals of current traumatic brain injury. There is no evidence of a diagnosis of traumatic brain injury at any time during the appellate period. In this regard, the Board finds that the December 2017 examiner's opinion that any such condition resolved is supported by the evidence of record; the opinion is afforded significant probative value. Moreover, traumatic brain injury is not listed as a chronic disability in 38 C.F.R. § 3.309(a); hence, reports of continuity of symptomatology do not assist the Veteran in this case. Walker, 708 F.3d at 1338-39. The Veteran lacks the competence to render a nexus opinion on such a complex medical question. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). As the evidence weighs against a finding of a nexus between service and claimed traumatic brain injury or residuals, or even current disability, entitlement to the benefit sought is not warranted. Memory Loss The Veteran specifically denied loss of memory on a report of medical history completed contemporaneously with her separation examination in April 1979. During screening for cognitive impairment in December 2017, the examiner noted the Veteran's memory complaints and noted the Veteran could not describe any memory issues. Both her remote and recent memory appeared good during evaluation. Quite simply, there is insufficient evidence of a disability manifested by memory loss. While the Veteran competently reports such symptoms, the complaints are not credible. Objective testing does not corroborate her complaints, and she herself was unable to provide any details aside from the bare allegation. The Board notes that memory loss is a potential symptom of mental health problems and of TBI. The former is granted above, while the latter is denied. In the absence of a current disability, separate and distinct from symptoms of PTSD or TBI, service connection is not warranted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Chronic Fatigue Syndrome Service treatment records do not reflect any findings or complaints of fatigue in active service. The Veteran underwent no treatment for chronic fatigue syndrome in active service. Her personnel records reveal that she lacked motivation for further military service in April 1979, and she had difficulty working under normal pressures of a military environment. Chronic fatigue syndrome was not diagnosed. A physical work performance evaluation in August 2015 reveals that the Veteran's overall level of work fell within the sedentary range. A brief musculoskeletal screen revealed bilateral total knee replacement, right knee pain with sit-to-stand, and pain with kneeling. Testing had lasted 2 hours 29 minutes, and the evaluator observed physiological signs of fatigue. A June 2016 examination report reveals that the Veteran had never been diagnosed with chronic fatigue syndrome. There is neither a medical history of chronic fatigue, nor signs nor symptoms of chronic fatigue syndrome. Recent VA records show no treatment for chronic fatigue syndrome. Rather, fatigue is noted only with regard to functional loss due to disabilities of the lumbar spine and neck and shoulders, and with regard to symptoms of depression and anxiety. For purposes of service connection for chronic fatigue syndrome, a current disability is not demonstrated. Instead, it appears the Veteran is seeking service connection for a symptomfatigueand not a separately diagnosed disability. The Board notes that fatigue is an accepted symptom of psychiatric disabilities; a claim for such is addressed in the remand below. To the extent that the Veteran asserts a nexus to active service or to service-connected disease or injury, she is competent to report fatigue both in service and after service. She is not, however, competent to diagnose chronic fatigue syndrome as opposed to complaints of fatigue. In this case, there is no showing of a current chronic fatigue syndrome. The evidence weighs against granting service connection for chronic fatigue syndrome. The benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. Tinnitus The Veteran contends that the onset of tinnitus was during active service. She reported exposure to acoustic trauma while working in the motor pool in active service. She later was diagnosed with tinnitus. As noted above, the Veteran is competent to testify on factual matters of which she has first-hand knowledge. Washington, 19 Vet. App. at 368. Furthermore, her statements are consistent with the circumstances of her service, and the Board finds there is credible evidence of longstanding tinnitus. Service treatment records show that the Veteran presented to the Emergency Room with complaints of earache of two days' duration in July 1977. Reportedly, her right ear started hurting the previous night, with increasing pains. Following examination, the assessment was early otitis media; medications were prescribed. The Veteran again reported sore throat and ear pain, right greater than left, of five days' duration in September 1977; no tinnitus was reported. In February 1978, the Veteran complained of earache and dizziness; examination was within normal limits. Assessments in December 1978 included rhinitis and serous otitis; no tinnitus was reported. Clinical evaluation of the Veteran's ears was normal at her separation examination in April 1979. Post-service records show that the Veteran was evaluated for chronic serous otitis media in May 2012. Sudden right ear hearing loss was noted at the time. The Veteran reported no prior history of noise exposure. The assessment then was serous otitis media, chronic, with conductive hearing loss, improved with tympanocentesis. In September 2018, an assessment of moderate tinnitus with muffling was noted. An October 2018 examination report revealed that the Veteran had constant tinnitus. The Veteran underwent a VA examination in January 2019. She complained of constant daily tinnitus, which increased in severity over the years. Following examination, the January 2019 examiner opined that the Veteran's tinnitus was less likely than not caused by or a result of military noise exposure. The examiner reasoned that the Veteran had normal hearing at separation from active service, and there were no objective factors for which the etiology of tinnitus could be attributed. There were neither complaints nor diagnosis of tinnitus in active service. Because tinnitus more likely than not was found in association with hearing loss, tinnitus was not due to or aggravated by military noise exposure. Given the nature of the disability, the Veteran's credible lay statements, and the January 2019 opinion that attributes the Veteran's tinnitus to hearing loss, the Board finds that the Veteran's tinnitus had its onset in active service. See Hodges v. West, 13 Vet. App. 287, as amended (2000). Here, the Veteran reported longstanding tinnitus, which increased in severity over the years and now was constant. She had been treated for repeated serous otitis in active service. Decreased hearing was noted at times with assessments of chronic serous otitis. This competent and credible lay evidence outweighs the negative medical opinion of the January 2019 VA examiner. Accordingly, service connection is warranted for tinnitus. In reaching this decision, the Board has extended the benefit of the doubt to the Veteran. 38 U.S.C. § 5107. Tooth Loss The Board notes that determinations of service connection for dental treatment and for compensation purposes are separate claims. Only compensation is sought in the current appeal; there is no indication the appropriate AOJ has adjudicated the question of treatment. The Veteran contends that she had injuries to her teeth during active service. She indicated that the trauma of being "hit in the face by a ball" in June 1978 had loosened her teeth. She later suffered losses of two left top molars and two left bottom molars. The Veteran is competent to report what occurred in service because her statements regard her first-hand knowledge of a factual matter. To establish entitlement to service connection for a tooth, the Veteran must have sustained a combat wound or other in-service trauma. See 38 U.S.C. § 1712(c); 38 C.F.R. § 3.381(b). Mere dental treatment or cracking a tooth while eating is not sufficient to establish trauma. Similarly, broken bridgework due to injury is not dental trauma because it must be the injury of a natural tooth. Further, the term "service trauma" does not include the intended effects of treatment provided during the Veteran's active service. VAOPGCPREC 5- 97 (1997), 63 Fed. Reg. 15,556 (1997). Service dental records show impaction of a tooth (No. 32) in December 1977; extraction was recommended. The Veteran took medication for infected wisdom teeth in January 1978. As noted above, the Veteran was struck with a softball in June 1978; the assessment then was ecchymosis of right orbit. Facial series of X-rays were negative, and no injury to any teeth was documented. The Veteran underwent routine extraction of wisdom tooth (No. 17) in July 1978. In August 1978, she reported completing endo therapy (root canals) two years ago. The examiner noted previous treatment (Nos. 6, 7, 8, 9, 10, and 11) and noted poor oral hygiene; crowns could be obtained once oral hygiene was improved. Examination later that same month revealed tissue still inflamed, which bled easily; and extensive stain was noted. The Veteran was treated for caries (No. 4) in August 1978. In October 1978, she was treated for caries (No. 15) and treated primarily with sedation and extraction of remaining wisdom teeth (Nos. 1, 16, and 32). She was treated for recurrent caries (Nos. 10 and 11) in January 1979, and was referred for endo therapy consultation. She was treated for caries (Nos. 2 and 5) in April 1979. Both service treatment records and service dental records do not suggest any dental trauma to teeth. Post-service records include a May 2016 examination report, which described the extent of loss of teeth as follows: two left upper molars, and two left lower molars. The examiner indicated that the Veteran's loss of teeth was not due to trauma or disease. Private records, received in May 2020, reveal that tooth # 12 was extracted in January 2016; and tooth # 13 was extracted in March 2019. Tooth # 4 also was fractured and needed extraction. The overall evidence does not suggest that the Veteran's in-service dental treatment was associated with trauma. Under these circumstances, the Board must conclude that the Veteran has not presented a legally sufficient claim for the VA benefit sought, and the claim must be denied on that basis. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Temporomandibular Joint Disorder The Veteran seeks service connection for a temporomandibular joint disorder. Reportedly, she had problems with her jaw during active service when she was "hit in the face by a ball" in June 1978. Where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Layno v. Brown, 6 Vet. App. 465, 469-71 (1994). Service treatment records do not reflect any findings or complaints of temporomandibular joint disorder in active service. The Veteran underwent no treatment for jaw pain in active service. As noted above, facial series of X-rays were negative in June 1978. On a report of medical history completed by the Veteran at her discharge examination from active service in April 1979, she checked "no" in response to whether she ever had or now had severe tooth or gum trouble. A temporomandibular joint disorder was not diagnosed. Post-service records reveal no treatment for any temporomandibular joint disorder. An examination report completed by the Veteran's treating physician in May 2016 includes a diagnosis of temporomandibular joint and a date of diagnosis of 1979. The Veteran's medical history reflects such temporomandibular joint disorder. Examination in May 2016 revealed that the Veteran had not lost any part of the mandible or mandibular ramus. She lost neither condyloid of the mandible nor coronoid process of the mandible. She had no injury resulting in malunion or nonunion of either the mandible or the maxilla. No part of the maxilla and no part of the hard palate were lost. Loss of teeth was not due to loss of substance of body of maxilla or mandible, and masticatory surfaces could be restored by suitable prosthesis. The May 2016 examiner found no disfiguring scars to the Veteran's mouth or lips. There was no injury that resulted in impairment of mastication. The Veteran did not have partial or complete loss of the tongue. Nor did she have a speech impairment caused by any other tongue condition. The Veteran had not been diagnosed with osteomyelitis or osteoradionecrosis of the mandible, or with bisphosphonate-related osteonecrosis of the jaw. Her temporomandibular joint had no functional impact on her ability to work. In January 2017, the Veteran's treating physician noted that the Veteran's most recent dental surgery resulted in loss of two teeth and a 1.5 cm communication/ exposure into the left maxillary sinus, which requires reconstructive surgery including a bone graft and flap. Private records, received in May 2020, reveal that the Veteran was numb and choked on her food on left side in March 2016. There was some sore area on left maxilla. The Veteran was advised to let the "area mature for six months" so that it would become denser and toughen up. The surgeon noted that "things look good" and have "healed nicely." The Veteran required a "partial" to help with eating. For purposes of service connection for temporomandibular joint disorder, no examiner has attributed the Veteran's current temporomandibular joint condition to active service. The May 2016 treating physician's diagnosis of temporomandibular joint in 1979 is based on what the Veteran reported. Merely repeating the Veteran's assertion does not make it so. The May 2016 examination report suggesting onset in 1979 is lacking in foundation and not supported by the evidence of record, including service treatment records; hence, it lacks probative value. Neither signs nor symptoms of a current temporomandibular joint disorder are documented. The Veteran's reconstructive surgery following dental surgery required months to mature, and a partial to assist with eating. Neither the dental surgery not the reconstructive surgery has been associated with the Veteran's active service. To the extent that the Veteran asserts a nexus to active service or to service-connected disease or injury, she is competent to report jaw problems both in service and after service. However, no medical professional has indicated a possible link between a current temporomandibular joint disorder and service-connected disease or injury. While the Veteran may fervently believe in such a connection, as a layperson the Veteran lacks the competence to render a nexus opinion on such a complex medical question. Kahana, 24 Vet. App. at 435. Nothing in the record reflects that a temporomandibular joint disorder had its onset in active service. The Board is within its province to decide as to whether the evidence supports a finding of service incurrence. See Barr, 21 Vet. App. at 307. Here, there is no showing of pertinent disability in service, and no competent evidence linking a current temporomandibular joint disorder to active service or to a service-connected disability. In short, for the reasons and bases set forth above, the Board concludes that the preponderance of the evidence is against granting service connection for a temporomandibular joint disorder. On this matter, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 53-56. REASONS FOR REMAND Cervical Spine Service treatment records show that the Veteran fell in January 1979 and injured her back and left cervical dorsal junction. Physical examination at the time revealed tenderness to left scalene muscle and infrascapular area. There were cautious limited ranges of motion. X-rays revealed a mild degree of anterior osteophytes from dorsal vertebral bodies. There was no fracture or dislocation of cervical dorsal spine. The impression was acute cervical strain. A VA examiner in May 2017 diagnosed degenerative disc disease of cervical spine, and listed the date of diagnosis as May 2017. The Veteran reported a history of onset in active service, when she began experiencing neck and back pain after long marches with full equipment. The condition progressed, and she took medication. Pertinent findings noted in May 2017 included pain on examination and pain causing functional loss. X-rays revealed straightening of the normal curvature suggestive of muscle spasm, and cervical spondylosis with mild multi-level facet arthrosis and degenerative disc disease at C5-C6. The Veteran's cervical spine disability did not impact her ability to work. In a November 2017 addendum, a VA physician opined that the Veteran's current cervical spine disability was less likely than not related to the condition the Veteran received treatment for in service. The VA physician reasoned that the in-service condition resolved as there was no further sequela with normal separation examination, and current cervical spine disability was separate and distinct process with no relationship. The Veteran had a normal separation examination, and there were no immediate post-service records documenting a chronic neck condition. While the November 2017 VA physician offered a nexus opinion regarding direct service connection, no opinion was provided regarding secondary service connection. Service connection has been awarded for degenerative disc disease of lumbar spine. Here, a reasonable basis for a possible nexus is raised for secondary service connection, and examination or medical review is required; determinations of proximate cause and degree of aggravation, if possible, are especially important. McLendon v. Nicholson, 20 Vet. App. 79, 83-84 (2006). Right and Left Shoulders Service treatment records, dated in March 1978, show that the Veteran reported sharp pain at shoulder blade with deep inspiration; and reaching forward with right arm caused similar pain. There were no known trauma and no straining with heavy lifting. Examination revealed tenderness to palpation over right medial scapular muscles. The assessment was rhomboid strain. Heat was to be applied. Service treatment records show that the Veteran fell and injured her back, cervical spine, and right shoulder in January 1979. Physical examination at the time revealed "trapezium twisted;" there was increased pain on elevation of left arm, and tenderness to infrascapular area. X-rays of left shoulder were within normal limits. There was no fracture or dislocation of shoulder. A VA examiner in October 2017 diagnosed bilateral shoulder strain and bilateral rotator cuff tendonitis. The Veteran reported having shoulder pain since active service, which has progressively worsened. She cannot raise her arms above shoulder level, and reported functional loss due to pain in shoulders when lifting and carrying weights. Examination revealed that ranges of motion of each shoulder were decreased. X-rays revealed neither degenerative nor traumatic arthritis of either shoulder. Disabilities of right and left shoulders do impact her ability to work. The October 2017 examiner opined that the Veteran's current disabilities of bilateral shoulder were less likely than not caused by the in-service sharp shoulder pain noted in service treatment records. The examiner reasoned that no chronic bilateral shoulder condition was shown in service, and the separation examination revealed shoulders were normal. The October 2017 examiner also opined that current disabilities of bilateral shoulder were less likely than not proximately due to or the result of service-connected disability because the Veteran's cervical condition was not service-connected. As noted above, service connection has been awarded for degenerative disc disease of lumbar spine; and certain claims for service connection, including cervical spine disability, remain pending and currently remanded for additional development. The Board cannot make a fully informed decision on the issue of service connection for disabilities of bilateral shoulder because no VA examiner has opined whether the claimed disabilities are part and parcel of, or related to the service-connected degenerative disc disease of lumbar spine; or otherwise is related to degenerative disc disease of cervical spine, which remains pending. The Board cannot resolve this matter without further medical clarification. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(4). The matters are REMANDED for the following action: 1. Obtain updated VA treatment records for the period from May 2019 to the present. 2. Schedule a VA examination or medical review, as appropriate, to determine the nature and etiology of the Veteran's cervical spine disability; and to determine the nature and etiology of the Veteran's disabilities of bilateral shoulder. The claims file must be available and reviewed in such regards. Specifically, the examiner(s) must opine as to: (a) whether any disability of either shoulder or cervical spine is at least as likely as not related to in-service injury or diseaseincluding rhomboid strain noted in March 1978 and injuries to the Veteran's back and cervical spine and right shoulder noted in January 1979; and (b) whether any disability of either shoulder or cervical spine is at least as likely as not caused or aggravated by service, to include as secondary to service-connected degenerative disc disease of lumbar spine, or any other service-connected disability; and (c) whether any disability of either shoulder is at least as likely as not proximately due to the degenerative disc disease of cervical spine. A full and complete rationale for all opinions expressed is required. If the examiner feels that the requested opinions cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. Then, readjudicate the claims on appeal. If the benefits sought remain denied, issue a supplemental statement of the case and, after appropriate time for response, return the appeal to the Board if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mary C. Suffoletta 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.