Citation Nr: 21076654 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 18-38 379 DATE: December 27, 2021 ORDER A rating in excess of 20 percent for residuals of a compression fracture of the thoracic spine with intervertebral disc syndrome (IVDS) and arthritis is denied. Service connection for a left hip disorder is denied. Service connection for a left ankle disorder is denied. Service connection for a left foot disorder is denied. Service connection for dermatitis is denied. Service connection for an adjustment disorder with anxiety and depression is granted. Service connection for a chronic respiratory disorder is denied. Service connection for hypertension is denied. REMANDED Entitlement to a rating in excess of 20 percent for left ulnar neuropathy is remanded. Entitlement to a rating in excess of 20 percent for left lower extremity neuropathy is remanded. FINDINGS OF FACT 1. The Veteran's residuals of a compression fracture of the thoracic spine with IVDS and arthritis is manifested by pain and limitation of forward flexion to, at worse, 55 degrees. 2. The preponderance of the evidence is against finding that a left hip disorder began during active service, or is otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that a left ankle disorder began during active service, or is otherwise related to an in-service injury or disease. 4. . The preponderance of the evidence of record is against finding that the Veteran has had a left foot disorder at any time during or approximate to the pendency of the claim. 5. The preponderance of the evidence is against finding that a chronic skin disorder began during active service, or is otherwise related to an in-service injury or disease. 6. . The Veteran's adjustment disorder with anxiety and depression is proximately due to his service-connected disabilities. 7. The preponderance of the evidence is against finding that a chronic respiratory disorder began during active service, or is otherwise related to an in-service injury or disease. 8. The Veteran's hypertension was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; the disability is not otherwise etiologically related to an in-service injury or disease; and the disability is not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 20 percent for residuals of a compression fracture of the thoracic spine with IVDS and arthritis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5243. 2. The criteria for service connection for a left hip disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for left ankle strain have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a left foot disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for dermatitis have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for an adjustment disorder with anxiety and depression as secondary to service-connected disabilities have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 7. The criteria for service connection for a chronic respiratory disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1977 to May 1992. In February 2021, a video conference board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file. The case was remanded by the Board in May 2021. At that time, the issues were remanded for further development of the evidence. This was accomplished and service connection was established for a left knee disability. The remaining issues on appeal have been returned for further appellate consideration. Entitlement to a rating in excess of 20 percent for residuals of a compression fracture of the thoracic spine with intervertebral disc syndrome (IVDS) The Veteran contends that his thoracic spine disorder, residuals of a compression fracture, is more disabling than currently evaluated. During the hearing before the undersigned in February 2021, he testified that his disorder had worsened since the last examination, which was conducted in 2017. As a result, the claim was remanded in May 2021 for a current VA examination. The Veteran's thoracic spine disorder is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5243, for intervertebral disc syndrome (IVDS). Diagnostic Code 5243 provides that IVDS is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Board notes that, effective February 7, 2021, Diagnostic Code 5243 was amended to read: "Intervertebral disc syndrome: Assign this diagnostic code only when there is disc herniation with compression and/or irritation of the adjacent nerve root; assign diagnostic code 5242 for all other disc diagnoses." This is rated under the General Rating Formula for Diseases and Injuries of the Spine. The Formula for Rating IVDS Based on Incapacitating Episodes provides that a 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Note 1 to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note 1. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent evaluation is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, or surgical procedure." Dorland's Illustrated Medical Dictionary, 94 (32nd ed. 2012). Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. Id. at Note 5. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In Correia v. McDonald, 28 Vet. App. 158 (2016), the United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." The spine has no opposite joint. In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. Service connection for residuals of a fracture of a thoracic spine vertebra was granted by rating decision dated in 2004. An initial 10 percent rating was made at that time. The Veteran requested an increased rating on November 10, 2016. Following examination, the rating was increased to 20 percent, effective the date of claim for an increased rating. The Veteran appealed this rating. An examination was conducted by VA in April 2017. The diagnosis was vertebral fracture. The Veteran stated he had trouble from the waist down and daily back pain. This started as mild sharp pain, but became quite severe throughout the day. These were described as flare-ups. Functional loss was described as causing him to stop gardening, hard work, or climbing ladders. The Veteran stated that he could do anything that required stooping and bending. Range of motion of the thoracolumbar spine was forward flexion to 60 degrees, extension to 20 degrees, right and left lateral flexion to 20 degrees and right and left lateral rotation to 25 degrees. The decreased range of motion did not contribute to functional loss. Pain was noted on forward flexion, extension, and right and left lateral flexion. There was no evidence of pain with weight bearing. There was objective evidence of localized tenderness or pain on palpation in the mid thoracic spine. The Veteran was able to perform repetitive use testing without additional loss of function. It was noted that he was being examined immediately after repetitive use over time with range of motion noted to be forward flexion to 50 degrees, extension to 10 degrees, right lateral flexion to 20 degrees, left lateral flexion to 15 degrees, and right and left lateral rotation to 20 degrees. The examination was not being conducted during a flare-up. The examiner was not able to state whether there was additional limitation of function during a flare-up without resorting to speculation. There was no guarding or muscle spasm. Muscle strength testing was decreased to 4/5 in left hip flexion, with all other testing normal at 5/5. There was no muscle atrophy. Reflexes were normal. Sensory examination showed decreases in the upper left anterior thigh and left thigh and knee. Straight leg raising tests were negative. There was radiculopathy with constant pain at times. There was mild radiculopathy on the left noted. There was no ankylosis of the spine. The examiner indicated the Veteran had IVDS, but did not have any episodes of acute signs or symptoms that required bed rest prescribed by a physician. The Veteran utilized a back brace on occasion. There was no pain with non-weight bearing or with weight bearing. Nerve conduction studies showed abnormalities of the left lower extremity. The Veteran's spine disorder did affect his ability to work in that it would impact his ability to perform activities such as heavy lifting, pushing, pulling, prolonged walking or standing. An examination was conducted by VA in June 2021. The diagnoses were IVDS and compression fracture of the thoracic spine with IVDS, and osteoarthritis of the thoracic spine. The Veteran's current symptom included sticking pain in his back. He took Hydrocodone and Naproxen for treatment. He stated that he had pain throughout the day that was increasing. His medication did "not touch his pain." He described it as severe. He reported functional loss as an inability to stand or walk for long periods and an inability to lift or carry anything mildly heavy. Range of motion was forward flexion to 60 degrees, extension to 15 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 20 degrees. Pain was noted in all planes of movement. Passive range of motion was performed without additional limitation of motion, but pain was also noted in all planes of movement. The Veteran was able to perform repetitive use testing without additional functional loss. He was not examined after repetitive use over time, but it was estimated that range of motion after repetitive use over time would be forward flexion to 55 degrees, extension to 15 degrees right and left lateral flexion to 15 degrees and right and left lateral rotation to 15 degrees. Similarly, the Veteran was not examined during a flare-up, but range of motion was estimated to be limited to the values after repetitive use over time. The Veteran did have muscle spasm and guarding, but this did not result in abnormal gait or spinal contour. It was noted that the Veteran's back disorder interfered with standing and disturbed locomotion. Muscle strength testing was normal, with no muscle atrophy. Reflexes were 2+ and equal. Sensory examination was decreased on the left lower extremity. Straight leg raising was positive on the left. Radiculopathy was noted with moderate constant pain, mild paresthesias, and mild numbness of the left lower extremity. This noted involvement of the left sciatic nerve roots. There was no ankylosis. The Veteran had IVDS, but this did not result in episodes of acute signs and symptoms that required bed rest prescribed by a physician or treatment over the last 12 months. It was noted that the Veteran was retired and that his thoracic spine disorder with IVDS made it difficult to do a lot of standing, walking or bending. A prior X-ray study performed in 2017 had shown osteoarthritis associated with the old compression fracture of the thoracic spine. The Board finds that the preponderance of the evidence is against a rating in excess of 20 percent for the thoracic spine disability based on incapacitating episodes. While the Veteran has been diagnosed as having IVDS, the evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. This was noted on both VA examinations and the Veteran has not contended otherwise. The preponderance of the evidence is also against a rating in excess of 20 percent for the Veteran's thoracic spine disorder under the General Rating Criteria. The Board acknowledges the Veteran's lay reports of symptoms and that there has been functional loss due to pain, but even considering the Veteran's lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements does not result in limitation of motion more nearly approximating forward flexion of the thoracolumbar spine to 30 degrees or less; or favorable ankylosis of the entire thoracolumbar spine. In this regard, the VA examiner estimated that loss of range of motion after repetitive use over time or during a flare-up would be forward flexion to 55 degrees at worst. Ankylosis also has not been shown at any time. Regarding neurological impairment, the Veteran has already been granted service connection for left lower extremity neuropathy, which will be addressed in the remand portion of this decision. The lay and medical evidence of record is against a finding that the Veteran has any other neurological abnormality associated with his spine disability. Based on the foregoing, the preponderance of the evidence is against of the evidence is against the Veteran's claim for a rating in excess of 20 percent for residuals of a compression fracture of the thoracic spine, with IVDS and arthritis. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. SERVICE CONNECTION Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, as identified in 38 C.F.R. § 3.309(a), noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also 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). Where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as hypertension, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. In order to prevail on the issue of service connection, there must be medical evidence of current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1990). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1990); 38 C.F.R. § 3.303(a). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Left hip disorder The Veteran contends that service connection should be established for a left hip disorder. It is asserted that he sustained an injury of the left hip in motor vehicle accidents (MVA) in which he was involved while on active duty. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of osteoporosis of the left hip, and evidence shows that he was involved in an MVA in service, the preponderance of the evidence weighs against finding that the Veteran's diagnosis of left hip disability began during service or is otherwise related to an in-service injury, event, or disease. In this regard, the record shows that while the Veteran was involved in a motorcycle accident in October 1971 and an MVA in January 1981, no abnormality of the left hip was demonstrated following those accidents. X-ray studies performed in January 1981 showed no radiographic abnormality. On examination by VA in July 1992, no abnormality of the left hip was noted. An X-ray study of the left hip conducted in February 2011 showed no abnormality. VA treatment records show the Veteran was not diagnosed with osteoporosis of the left hip until August 2015, years after his separation from service. While the Veteran is competent to report having experienced symptoms of left hip pain since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of osteoporosis that was shown in 2015. The issue is medically complex, as it requires knowledge of the interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran was afforded two VA examinations during the pendency of his appeal. In August 2016, it was found that the Veteran did not have a current diagnosis associated with an in-service left hip injury. After examination in June 2021, the VA examiner opined that the Veteran's left hip osteoporosis was less likely than not incurred in or caused by a claimed in-service injury, event, or illness. The rationale was that the Veteran had a current diagnosis of left hip osteoporosis, but that no medical evidence had been found to show that the Veteran had been seen for a left hip condition while in service so there was no nexus established. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). It is important to note that the only medical opinions on record find no nexus between the Veteran's service and the development of his left hip disorder. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a left hip disability, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Left ankle disorder The Veteran contends that service connection should be established for a left ankle disorder, which he asserts is related to the MVAs in which he was involved during service. As with the left hip, the question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. After review of the record, the Board concludes that, while the Veteran was involved in MVAs while on active duty, the preponderance of the evidence weighs against finding that the Veteran's diagnosis of left ankle strain began during service or is otherwise related to an in-service injury, event, or disease. Post-service treatment records show the Veteran was not diagnosed with left ankle strain until June 2021, years after his separation from service. It is significant that on examination by the VA in February 2011, no pathology upon which a diagnosis of a left ankle disorder could be made was found. While the Veteran is competent to report having experienced symptoms of left ankle pain since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of his current left ankle strain. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau 492 F.3d at 1372. Further, the June 2021 VA examiner opined that the Veteran's current left ankle strain was not at least as likely as not related to an in-service injury, event, or disease. The rationale was that there was no medical evidence that the Veteran had a left ankle injury while in service so that any current left ankle strain that was now diagnosed was not shown to be caused by an in-service injury or incident. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez 22 Vet. App. at 295. This is the only medical opinion in the record and, as noted, the Board may not reject medical opinions based on its own medical judgment. Obert 5 Vet. App. at 30; Colvin 1 Vet. App. at 171. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a left ankle strain, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Left foot disorder The Veteran contends he has a left foot disorder that is related to the MVAs in which he was involved in while on active duty. Review of the record shows the Veteran was noted to have an injured left foot in the motorcycle accident in which he was involved while he was on active duty. It is noted further that X-ray studies performed following the accident showed no abnormality. The question for the Board, however, is whether the Veteran has a current disability that began during service or is at least as likely as not related to that in-service injury or any other event or disease in service. After review of the record, the Board concludes that the Veteran does not have a current diagnosis of a chronic left foot disorder and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In reaching this conclusion, the Board has considered Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), in which the Federal Circuit held that "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability" if it "reaches the level of a functional impairment of earning capacity." Id. at 1367-69. However, VA treatment records do not contain a diagnosis of a chronic left foot disorder. It is also noted that on VA examination in February 2011, X-ray studies of the left foot were negative, and no pathology of the left foot was found. Most recently, the Veteran was examined by VA in June 2021. At that time, the Veteran reported having pain in the left foot that affected his ability to stand or walk for long periods. An examination of the left foot was normal. The VA examiner evaluated the Veteran and determined that the Veteran did not have a diagnosis of a left foot disability. The examiner further noted that the Veteran was retired, but when he did work, he had lost 0-1 weeks (out of a year) in work time due to his left foot pain making it difficult for him to do a lot of walking and standing. Based on these symptoms, it is not shown that the Veteran's left foot pain has reached the level of a functional impairment of earning capacity. While the Veteran believes he has a current diagnosis of a left foot disorder, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education. Jandreau, 492 F.3d at 1372. Consequently, the Board gives more probative weight to the competent medical evidence. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a left foot disorder, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Dermatitis The Veteran contends that service connection should be established for a chronic skin disorder that has now been diagnosed as dermatitis. During the Board hearing before the undersigned, the Veteran testified that he was treated for skin abnormalities while he was on active duty. It was pointed out also that he had provided private treatment records documenting treatment for a skin disorder. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. After review of the record, the Board concludes that, while the Veteran has a current diagnosis of dermatitis, the preponderance of the evidence weighs against finding that the Veteran's current skin disorder began during service or is otherwise related to an in-service injury, event, or disease. In this regard, review of the record shows no complaints or treatment for a chronic skin disorder while the Veteran was on active duty. Private treatment records dated in April 2013 show the Veteran was treated for complaints of intense itching when examination disclosed lichenified, excoriated plaque on the left pretibial consistent with lichen simplex chronicus/neurodermatitis. The treatment provider did not render an opinion regarding the etiology of the skin disorder at that time. As noted, the Veteran is competent to report having experienced symptoms of a skin disorder since service, but he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of chronic dermatitis of service onset. Jandreau 492 F.3d at 1372. The Veteran was examined by VA in June 2021. At that time, the diagnosis was psoriasis. Following examination, the VA examiner opined that the Veteran's skin disorder was not at least as likely as not related to an in-service injury, event, or disease. The rationale was that there was no medical evidence that the Veteran's psoriasis was manifested during service. Therefore, it was less likely than not that this was caused by any dermatitis that the Veteran may have manifested during service. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez 22 Vet. App. at 295. This is the only medical opinion in the record and, as noted, the Board may not reject medical opinions based on its own medical judgment. Obert 5 Vet. App. at 30; Colvin 1 Vet. App. at 171. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a chronic skin disorder, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Adjustment disorder with anxiety The Veteran contends that service connection should be established for a chronic acquired psychiatric disorder that he believes is related to service. The Board concludes that the Veteran has a current disability that is related to his period of active duty. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). "When aggravation of a veteran's non-service-connected condition is proximately due to or the result of a service-connected condition, such veteran shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation." Allen v. Brown, 7 Vet. App. 439 (1995). A September 2019 private psychiatric examination report shows the Veteran has a current diagnosis of adjustment disorder with mixed anxiety and depressed mood. The examiner stated that this is secondary to the stress of having to live with service-connected general medical conditions. The Board notes that the Veteran is currently service-connected for: left knee chondromalacia, rated 20 percent disabling; degenerative disc disease of the cervical spine, rated 20 percent disabling; residuals of a compression fracture of the thoracic spine, with IVDS and arthritis, rated 20 percent disabling; left ulnar neuropathy, rated 20 percent disabling; left lower extremity neuropathy, rated 20 percent disabling; degenerative joint disease with tendonitis, rated 10 percent disabling and tinnitus, rated 10 percent disabling. The evidence in favor of the claim also includes a VA examination dated in July 2021 that included a diagnosis of adjustment disorder with mixed anxiety and depressed mood. The etiology was commented to be chronic pain due to degenerative joint disease with tendonitis, a compression fracture of the thoracic spine with low back pain, degenerative disc disease and degenerative joint disease of the cervical spine and left lower extremity neuropathy. After first indicating that the Veteran's psychiatric disorder was less likely than not caused by an in-service injury, event, or illness, the examiner went on to opine that the Veteran described chronic pain as related to his service-connected conditions. Thus, there was sufficient nexus linking his current mental health condition to his service-connected conditions and it is at least as likely as not that the adjustment disorder with mixed anxiety and depressed mood is secondary to the chronic pain from a combination of his service-connected tendonitis, compression fracture, cervical spine disorder and neuropathy. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current adjustment disorder is proximately due to his service-connected disabilities. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for adjustment disorder with anxiety and depression is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102." A chronic respiratory disorder The Veteran contends that service connection should be established for a chronic respiratory disorder that he states had its onset during service. During the hearing before the undersigned, it was pointed out that he was treated for chest tightness during service when he underwent pulmonary function testing. He stated that at the time he was diagnosed with chronic obstructive pulmonary disease (COPD) in 2004 he had the same symptoms that were noted during service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of COPD, and evidence shows that he was treated for chest tightness and underwent pulmonary function testing during service, the preponderance of the evidence weighs against finding that the Veteran's diagnosis of COPD began during service or is otherwise related to an in-service injury, event, or disease. Review of the Veteran's service treatment records (STRs) shows that on periodic examination in June 1984 it was reported that the Veteran had had moderate seasonal sinusitis since 1980 and had been treated for drainage with the last episode being in the fall of 1983. It was also indicated that the Veteran had been treated with good results by medication and was currently asymptomatic. Pulmonary function testing performed at that time showed normal values. On examination in April 1989, clinical evaluation of the lungs was normal and pulmonary function testing was within normal limits. The STRs do not show the Veteran was diagnosed with COPD in service. Post-service medical evidence includes the report from a July 1992 VA general medical examination that showed evaluation of the respiratory system to be normal. VA outpatient treatment records show that the Veteran's COPD was diagnosed in July 2003. VA outpatient treatment records dated in July 2013 include diagnoses of COPD and allergic rhinitis. An examination was conducted by VA in June 2021. The diagnosis at that time waws COPD. Following examination, the examiner opined that the Veteran's respiratory disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale was that the main cause of COPD was cigarette smoking, which the Veteran ceased in 2003. The examiner stated further that the Veteran was diagnosed with COPD in 2004. It was noted that during service the Veteran was only seen for a chest contusion and tightness in the chest. However, the examiner explained these conditions would not necessarily cause a chronic condition. The examiner concluded the Veteran's chronic respiratory disorder was less likely than not caused by respiratory issues while in service. The treatment records show the Veteran was not diagnosed with COPD until 2004, years after his separation from service. While the Veteran is competent to report having experienced symptoms of tightness in his chest that are similar to the symptoms that he experienced when diagnosed with COPD since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of COPD. The issue is medically complex, as it requires knowledge of the interpretation of complicated diagnostic medical testing. Jandreau 492 F.3d at 1372. Review of the record shows no evidence of a chronic respiratory disorder during service with two pulmonary function studies shown to be normal. COPD was not manifested until 2004 soon after the Veteran stopped smoking. The June 2021 VA examiner opined that the Veteran's COPD is more likely the result of smoking. The examiner's opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez 22 Vet. App. at 295. This is the only medical opinion in the record and, as noted, the Board may not reject medical opinions based on its own medical judgment. Obert 5 Vet. App. at 30; Colvin 1 Vet. App. at 171. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for a chronic respiratory disorder, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Hypertension The Veteran contends that service connection should be established for hypertension. During the hearing on appeal, his main contention was that this disorder was caused or aggravated by pain from his service-connected disorders, but the matter of direct service connection has also been addressed by VA. Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). The Veteran has a current diagnosis of hypertension as evidenced by a VA examination dated in June 2021. Hypertension is an enumerated condition under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. Review of the record, however, shows no evidence that the disability was shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. Review of the Veteran's STRs shows no evidence of hypertension with blood pressure readings normal. The Veteran's blood pressure was also normal on examination by VA in July 1992, when it was recorded as 118/80. An examination was conducted by VA in June 2021. The diagnosis was hypertension. Following examination, the examiner addressed direct and secondary service connection. Regarding direct service connection it was opined that the hypertension was less likely than not incurred in or caused by a claimed in-service injury, event, or illness. The rationale was that the Veteran was not diagnosed with hypertension until some 20 to 30 years after military service. Blood pressure readings on at least two occasions during service were normal and other risk factors were more likely to have led to the Veteran's hypertension. These included age, gender, and cigarette smoking. Regarding secondary service connection the examiner opined that the other risk factors already noted were more likely to have led to the Veteran's hypertension. As such, it was less likely than not caused by or aggravated beyond its natural progression by any service-connected disability. VA treatment records show the Veteran was diagnosed with hypertension in July 2013, years after his separation from service and years outside of the applicable presumptive period. While the Veteran is competent to report having experienced symptoms of hypertension since service, it is noted that during the hearing before the undersigned, he acknowledged that he was first noted to have hypertension years after service and stated his main contention is that he believed his hypertension was secondary to pain from his service-connected disabilities. As with his other disorders, it has been found that he is not competent to provide a diagnosis in this case or determine that hypertension is related to his service-connected disorders as he has not demonstrated the necessary medical expertise. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau 492 F.3d at 1372. The Board gives more probative weight to competent medical evidence, which establishes that these symptoms are instead attributable to the Veteran's age, gender and history of smoking. For these reasons, the Board finds that a preponderance of the evidence is against the Veteran's claim for service connection for hypertension, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND Ratings for left ulnar and lower extremity neuropathy is remanded. After the most recent Supplemental Statement of the Case (SSOC) was furnished by the Agency of Original Jurisdiction (AOJ), additional VA reatment records were associated with the Veteran's claims folder. The Veteran and his representative were given the opportunity to waiver AOJ consideration of this evidence, but did not respond to the notification letter. Therefore, in accordence with that notification, these issues are remanded for issuance of an SSOC. The matters are REMANDED for the following action: (Continued on the next page) The AOJ should send the Veteran and his representative a SSOC and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. A. ISHIZAWAR Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Joseph P. Gervasio 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.