Citation Nr: 21005698 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 16-14 166 DATE: February 2, 2021 ORDER 1. Entitlement to service connection for a left knee disability, to include arthritis, is denied. 2. Entitlement to service connection for a right knee disability, to include arthritis, is denied. 3. Entitlement to service connection for a lumbar spine disability, to include degenerative disc disease, is denied. 4. Entitlement to service connection for a scar on the left arm is denied. 5. Entitlement to service connection for a scar on the left knee is denied. 6. Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. REMANDED 7. Entitlement to service connection for a right foot disability is remanded. 8. Entitlement to service connection for a left foot disability is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding a left knee disability had an onset in service, manifested to a compensable degree within one year of service discharge, or is otherwise related to service. 2. The preponderance of the evidence is against finding a right knee disability had an onset in service, manifested to a compensable degree within one year of service discharge, or is otherwise related to service. 3. The preponderance of the evidence is against finding a lumbar spine disability had an onset in service or is otherwise related to service. 4. The scar on the left arm was noted on the January 1974 entrance examination, and the preponderance of the evidence is against finding that the scar on the left arm was aggravated during service. 5. The scar on the left knee was noted on the January 1974 entrance examination, and the preponderance of the evidence is against finding that the scar on the left knee was aggravated during service. 6. The Board does not find the Veteran has credible supporting evidence that a stressor occurred. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left knee disability, to include arthritis, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 2. The criteria for entitlement to service connection for a right knee disability, to include arthritis, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 3. The criteria for entitlement to service connection for a lumbar spine disability, to include degenerative disc disease, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 4. The criteria for entitlement to service connection for a scar on the left arm have not been met. 38 U.S.C. §§ 1110, 1131, 1153, 5107 (2012); 38 C.F.R. §§ 3.102, 3.102, 3.303, 3.306 (2019). 5. The criteria for entitlement to service connection for a scar on the left knee have not been met. 38 U.S.C. §§ 1110, 1131, 1153, 5107 (2012); 38 C.F.R. §§ 3.102, 3.102, 3.303, 3.306 (2019). 6. The criteria for entitlement to service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 1153, 5107 (2012); 38 C.F.R. §§ 3.102, 3.102, 3.303, 3.304(f), 3.306, 4.125 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1974 to June 1977. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge in August 2019. A transcript of the hearing was prepared and associated with the claims file. The Board denied the above claims in a December 2019 decision. The Veteran appealed that decision to the U. S. Court of Appeals for Veterans Claims (Court). In August 2020, the Court granted a joint motion for remand (JMR), vacating the Board’s decision, as it related to the issues on appeal, and remanded the matter for compliance with the instructions in the JMR. In a November 2020 statement, the Veteran’s representative requested that VA provide any additional evidence added to the file since the time of the Board decision. The Board notes that no additional evidence, other than evidence submitted by the Veteran’s representative, has been added to the file since that time. Thus, the Board will proceed with review. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as arthritis, which is also known as degenerative joint disease, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a). 1. – 2. Entitlement to service connection for a bilateral knee disability The Veteran testified in August 2019 that he believes that his bilateral knee disability was caused by his service. He testified that he had to carry approximately 170 to 200 pounds of gear on 15- to 30-mile long patrols. He asserts that this weight and distance put pressure on his knees and caused his current bilateral knee disability. The Veteran asserts he started experiencing pain in his knees when he got out of service because he was not walking properly and that the pain in his knees contributed to his decision to not reenlist, as his body was wearing down. The Veteran also reported in his June 2015 notice of disagreement that he crawled on his knees in the field frequently during his service. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a bilateral knee disability. The reasons follow. As to evidence of a current disability, July 2013 VA treatment records document a diagnosis of arthritis in the bilateral knees. March 2014 VA treatment records document a diagnosis of degenerative joint disease and arthralgia in the bilateral knees. Therefore, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, the service treatment records (STRs) do not show that the Veteran sustained a disease or injury to the bilateral knee during service. Had the Veteran experienced symptomatology related to his knees in service, the Board finds it is likely he would have reported it, given that he reported multiple instances of pain in his feet during service, including in December 1974 and February 1976. Additionally, the June 1977 separation examination shows that clinical evaluation of the lower extremities was normal. The only documentation on the separation examination suggesting a clinical abnormality related to the knees at separation was the notation of a scar on the left knee (which will be addressed separately). Furthermore, the Veteran signed a statement on the separation examination noting that he was aware that he should report any defects, whether disqualifying for service or not, for the purposes of entitlement to benefits from the Veterans Administration. Presumably in signing this, the Veteran understood that the examination was an opportunity report any and all incidents or injuries in service, and the Veteran did not report any symptomatology related to either knee. The Veteran testified that he did not report symptoms of pain in his bilateral knee during service, as it was his belief that Marines did not complain about or report symptoms of pain, and, had he reported such symptomatology, he believed he may have been penalized and/or not received promotions. However, as noted above, the STRs document that the Veteran reported symptoms of pain in his feet on multiple occasions throughout his service. Beyond his feet, the Veteran sought treatment for a foreign body in his eye in November 1974; symptoms of a sore throat in March 1975; symptoms of pain in his abdomen in July 1976; symptoms of pain when breathing in July and September 1976; and symptoms of malaise, headaches, and weakness in March 1977. The Board finds the Veteran’s testimony is not credible, as the contemporaneous STRs do not show that the Veteran was afraid to report pain or other symptoms to treatment providers in service. On the contrary, the STRs show he reported symptoms to medical personnel on multiple occasions as it related to other injuries or illnesses. The Board finds that carrying a heavy backpack while walking or crawling on his knees are not diseases or injuries. The preponderance of the evidence is against evidence of complaints or symptoms related to a bilateral knee disability during service, and the in-service disease or injury element is not met. The Board also finds that the preponderance of the evidence is against a nexus between the current bilateral knee disability and service. For example, of record are private treatment records dated from January 2005 to March 2011, which document complaints and treatment for abdominal pain with nausea, vomiting, and diarrhea, a burn on his right outer foot, hypertension (on five occasions), right groin pain, fever/body aches, sores on the back of his jaw and the base of the tongue, bilateral ear congestion, hemorrhoids, bilateral foot pain, and thick and brittle toenails. Except for one occasion, the examiner consistently documented that the, “Remaining [review of systems was] negative,” which would indicate that the Veteran was not reporting bilateral knee pain and which records cover a six-year period. A January 2009 medical record shows that the Veteran underwent a physical at that time. The report shows a positive medical history of hypertension. The examiner performed a review of systems, which were all documented as negative. The physical examination showed that the Veteran’s extremities were clear without edema. This particular record shows that the Veteran’s lower extremities were physically examined, and there were negative findings. The Board finds this is affirmative evidence that the Veteran was not experiencing chronic bilateral knee pain in January 2009. The examiner included a “Problem List,” which included blood in stool, hypertension, and tobacco abuse. It did not include bilateral knee pain. The Veteran’s report of his past medical history also did not include bilateral knee pain. Instead, it included hypertension only, which is consistent with the private medical records, which show that the Veteran had hypertension as a chronic condition between 2005 and 2011. At this point, it had been more than 30 years since service discharge with reviews of systems beginning in 2005 being negative and covering a six-year period and not including bilateral knee pain. The private medical records show that the Veteran sought treatment for various medical symptoms he was experiencing at the time, which did not include bilateral knee pain. The Board finds as fact that had the Veteran been experiencing chronic bilateral knee pain during this period, he would have reported it. This evidence supports the conclusion that the Veteran was not having ongoing knee pain in the years following service discharge. The Veteran reported bilateral knee pain in August 2011, when he first sought treatment by VA, which is more than 30 years after his discharge from service. This tends to establish that a bilateral knee disability did not have an onset in service, and this, along with the private medical records discussed above, shows that the Veteran had not been experiencing chronic symptoms of bilateral knee pain since service. In a December 2012 VA treatment record, the examiner documented that the Veteran reported he had been experiencing knee pain for 25 years, which suggests an onset of knee pain in approximately 1987, which is still 10 years after the Veteran’s discharge from service, although this report is inconsistent with what is documented in the contemporaneous private medical records from 2005 to 2011. For all the above reasons, the Board finds that the Veteran’s allegation of chronic bilateral knee pain in the years following service discharge is not credible. Accordingly, the preponderance of the evidence is against a finding that the bilateral knee pain, first reported and documented in 2011, is related to a disease or injury in service. Despite not meeting the requirements for service connection on a direct basis, the Board notes that degenerative joint disease and arthritis are chronic diseases under 38 C.F.R. § 3.309, which allows for service connection on a presumptive basis if the chronic disease is manifested to a compensable degree within one year of discharge from service. However, the preponderance of the evidence is against finding that the degenerative joint disease or arthritis involving the bilateral knee had an onset within one year of discharge from service. Rather, the earliest documentation in the claims file suggests an onset of arthritis in approximately July 2013. This is more than 30 years after the Veteran’s discharge from active service. Additionally, VA treatment records prior to July 2013, though they document pain and arthralgia in the left knee as early as August 2011, do not document a diagnosis of degenerative joint disease or arthritis prior to July 2013. In December 2012 VA treatment records, it was documented that the Veteran reported he had experienced left knee pain for approximately 25 years, suggesting an onset of symptomatic pain in the knee in approximately 1987, which is still 10 years after his discharge from service. The Board finds that this is highly probative evidence that the diagnosis of a chronic disease of arthritis was not made until approximately July 2013, which again, is decades after the Veteran’s discharge from active service, and the Board has laid out above why the preponderance of the evidence is against continuity of symptomatology since service discharge. Thus, the facts do not meet the criteria for service connection on a presumptive basis for a chronic disease involving the bilateral knee disability. Although the Veteran claims that his bilateral knee arthritis is related to service, he is not competent to directly link arthritis to service, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. As stated above, to the extent that the Veteran claims chronic symptoms in his knees during service and since service, the Board finds such statements not credible. Based on the aforementioned, the Board finds the preponderance of the evidence is against a relationship between a bilateral knee disability, to include arthritis, and service, and the nexus element is not met. The Veteran’s representative has asserted that a remand for a VA examination is warranted for these claims because the JMR requires examinations due to the Veteran’s lay evidence of continuous symptomatology indicates a potential link between the disability and an in-service event. However, the Board finds that the facts do not support entitlement to a VA examination or medical opinion for these claims. VA must provide a medical examination and/or medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The preponderance of the evidence is against three of the above criteria being met. For example, as explained above, the preponderance of the evidence is against an event, injury, or disease occurred in service or an indication that the disability may be associated with the Veteran’s service. While the Veteran, through his representative, has stated that the Veteran’s lay evidence of continuous symptomatology is sufficient to establish that the disability may be associated with service, the Board disagrees for two reasons. One, conclusory and generalized lay statements that an in-service event caused or is otherwise related to the Veteran’s current disability are insufficient to establish that it may be due to service. Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010) (noting that a contrary rule “would eliminate the carefully drafted statutory standards governing the provision of medical examinations and require the Secretary to provide such examinations as a matter of course in virtually every veteran's disability case”). Additionally, the Board has laid out above why it does not believe the allegation of continuity of symptomatology in the years following service discharge. The Board also finds that the evidence is sufficient to decide the claims at the present time. For a VA examination and/or medical opinion to be warranted, all the McLendon criteria must be met, and at least three of them are not met. Therefore, entitlement to a VA examination and/or medical opinion is not warranted for the service-connection claims involving the bilateral knee. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for a bilateral knee disability, to include arthritis, is denied. 3. Entitlement to service connection for a lumbar spine disability The Veteran testified in August 2019 that he believes that his lumbar spine disability was caused by his service. He testified that he had to carry approximately 170 to 200 pounds of gear on 15- to 30-mile long patrols. He asserts that this weight and distance put pressure on his spine and caused his current lumbar spine disability. He also asserts that the pain in his spine started when he got out of service because he was not walking properly and that the pain in his spine contributed to his decision to not reenlist as his body was wearing down. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a lumbar spine disability. The reasons follow. As to evidence of a current disability, November 2014 VA treatment records document a diagnosis of degenerative disc disease of the lumbar spine. Therefore, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, the STRs do not show that the Veteran sustained a disease or injury to the lumbar spine during service. Had the Veteran experienced symptomatology related to his lumbar spine in service, the Board finds it is likely he would have reported it, given that he reported multiple instances of pain in his feet during service, including in December 1974 and February 1976. Additionally, at the June 1977 separation examination, a clinical evaluation of the spine and musculoskeletal system was normal. Furthermore, the Veteran signed a statement on the examination noting that he was aware that any defects, whether disqualifying for service or not, would be reported on the examination for the purposes of entitlement to benefits from the Veterans Administration. Presumably in signing this, the Veteran understood that the examination was an opportunity report any and all incidents or injuries in service, and the Veteran did not report any symptomatology related to his lumbar spine. The Veteran testified that he did not report symptoms of pain in his lumbar spine during service, as it was his belief that Marines did not complain about or report symptoms of pain, and had he reported such symptomatology he believed he may have been penalized and/or not received promotions. However, as noted above, the STRs document that the Veteran reported symptoms of pain in his feet on multiple occasions throughout his service. Beyond his feet, the Veteran reported a foreign body in his eye in November 1974; symptoms of a sore throat in March 1975; symptoms of pain in his abdomen in July 1976; symptoms of pain when breathing in July and September 1976; and symptoms of malaise, headaches and weakness in March 1977. The Board finds the Veteran’s testimony is not credible as the contemporaneous STRs do not show that the Veteran was afraid to report pain or other symptoms to treatment providers in service. On the contrary, these records show he reported symptoms to treatment providers in service on multiple occasions as it related to other injuries or illnesses. The Board finds that carrying a heavy backpack while walking is not a disease or injury. The preponderance of the evidence is against complaints or symptoms related to the onset of a lumbar spine disability during service, and the in-service disease or injury element is not met. The Board also finds that the preponderance of the evidence is against a nexus between the current lumbar spine disability and service. For example, of record are private treatment records dated from January 2005 to March 2011, which document complaints and treatment for abdominal pain with nausea, vomiting, and diarrhea, burn on his right outer foot, hypertension and hypertriglyceridemia (on five occasions), right groin pain, fever/body aches, sores on the back of his jaw and the base of the tongue, bilateral ear congestion, hemorrhoids, bilateral foot pain, and thick and brittle toenails. Except for one occasion, the examiner consistently documented that the, “Remaining [review of systems was] negative,” which would indicate that the Veteran was not reporting lumbar spine pain and which records cover a six-year period. A January 2009 medical record shows that the Veteran underwent a physical at that time. The report shows a positive medical history of hypertension. The examiner performed a review of systems, which were all documented as negative. The physical examination does not document a specific examination of the spine; however, the examiner documented positive clinical findings and negative clinical findings, and the Board finds that had the Veteran been experiencing chronic lumbar spine pain, he would have reported it at that time, and the examiner would have documented such positive finding. The examiner included a “Problem List,” which included blood in stool, hypertension, and tobacco abuse. It did not include lumbar spine pain. Instead, it included hypertension only, which is consistent with the private medical records, which show that the Veteran had hypertension as a chronic condition between 2005 and 2011. The Board finds this is evidence that tends to show the Veteran was not experiencing chronic lumbar spine pain in January 2009. At this point, it had been more than 30 years since service discharge with reviews of systems beginning in 2005 being negative and covering a six-year period and not including lumbar spine pain. The private medical records show that the Veteran sought treatment for various medical symptoms he was experiencing at the time, which did not include lumbar spine pain. The Board finds as fact that had the Veteran been experiencing chronic lumbar spine pain during this period, he would have reported it. This evidence supports the conclusion that the Veteran was not having ongoing lumbar spine pain in the years following service discharge. The evidence documents that the Veteran first complained of pain in his lumbar spine in July 2013 VA treatment records, more than 35 years after service discharge. When the Veteran first sought treatment with VA in August 2011, there was an area within the notes where the examiner could document “Significant Health Problems,” which included “Back Problems.” That health problem was not checked. What was checked was hypertension, which is consistent with the January 2009 private physical examination report, when he reported a past medical history of hypertension, but no musculoskeletal pain and is consistent with the other private medical records from 2005 to 2011 described above, where the Veteran sought treatment regularly for hypertension. This is further evidence that tends to establish that a lumbar spine disability did not have an onset in service and that the Veteran had not been experiencing chronic lumbar spine pain since service. Although the Veteran claims that his lumbar spine disability is related to service, he is not competent to directly link degenerative disc disease of the lumbar spine to service, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. Based on the aforementioned, the Board finds the preponderance of the evidence is against a relationship between a lumbar spine disability and service, and the nexus element is not met. The Veteran’s representative has asserted that a remand for a VA examination is warranted for the claim for service connection for a lumbar spine disability because the JMR requires an examination due to the Veteran’s lay evidence of continuous symptomatology indicates a potential link between the disability and an in-service event. However, the Board finds that the facts do not support entitlement to a VA examination or medical opinion for this claim. See McLendon, 20 Vet. App. 79. Here, the Board finds that the preponderance of the evidence is against three of the criteria being met. For example, as explained above, the Board preponderance of the evidence is against an event, injury, or disease occurred in service or an indication that the disability may be associated with the Veteran’s service. While the Veteran, through his representative, has stated that the Veteran’s lay evidence of continuous symptomatology is sufficient to establish that the disability may be associated with service, the Board does not agree. Conclusory and generalized lay statements that an in-service event caused or is otherwise related to the Veteran’s current disability are insufficient to establish that it may be due to service. Waters, 601 F.3d at, 1278. Additionally, the Board has laid out above why it does not believe the allegation of continuity of symptomatology in the years following service discharge. The Board also finds that the evidence is sufficient to decide the claim at the present time. For a VA examination and/or medical opinion to be warranted, all the McLendon criteria must be met, and at least three of them are not met. Therefore, entitlement to a VA examination and/or medical opinion is not warranted for the service-connection claim involving the lumbar spine. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for a lumbar spine disability is denied. 4. – 5. Entitlement to service connection for a scar on the left arm and scar on the left knee The Veteran believes that his scar on the left arm and left knee were caused by falling on sticks or a tree branch in service. He reported on his March 2016 notice of disagreement that he got the scars while “playing war games” in service, and he reiterated this contention at his August 2019 hearing. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a scar on the left arm and a scar on the left knee. The reasons follow. As to evidence of a current disability, a March 2015 VA examination report shows that the Veteran was noted to have a painful scar on the left forearm and a painful scar on the left knee. Therefore, the facts establish that the first element of a service-connection claim is met. A veteran will be considered to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by service. 38 U.S.C. § 1111. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). A pre-existing disability will be considered to have been aggravated by active military service when there is an increase in disability during service, unless there is clear and unmistakable evidence (obvious and manifest) that the increase in disability is due to the natural progress of the disorder. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a), (b). Aggravation of a pre-existing condition may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). The January 1974 entrance examination documents that the Veteran had a scar on his left lower arm and on his left knee. Thus, the presumption of soundness does not attach with respect to a scar on the left arm and a scar on the left knee, and the only benefit that can be awarded for either scar is service connection on the basis of aggravation of the pre-existing disability. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. Therefore, the issue before the Board is whether the scar on the left arm and scar on the left knee were aggravated during service. Independent medical evidence is needed to support a finding that the preexisting disorder increased in severity in service. See Paulson v. Brown, 7 Vet. App. 466, 470–471 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1994). The question of whether there has been an increase in disability during service must be answered in the affirmative before presumption of aggravation attaches, so that presumption is unaffected by the rule on service connection for increase in disability during service. Verdon v. Brown, 8 Vet. App. 529 (1996); see also Falzone v. Brown, 8 Vet. App. 398, 402 (1995) (holding that the presumption of aggravation created by section 3.306 applies only if there is an increase in severity during service). As noted above, the Veteran testified at his August 2019 hearing that he believed that his left arm and left knee scars were caused by falling on a stick or branch in service. The Veteran’s representative argued in a statement submitted in November 2020 that the scars were aggravated during service because, though the scars were noted at entrance, the scars were not noted to be painful at entrance; thus, the representative concluded that the scars were aggravated during service because the March 2015 VA examination documented that the scars were now painful. The Board acknowledges that the scars were documented to be painful when the Veteran underwent the VA examination in March 2015. However, the March 2015 VA examination was conducted more than 35 years after the Veteran’s discharge from active service. To show aggravation, the burden is on the Veteran to show that the disability was aggravated during service. The STRs do not document that the scars became painful in service. At the Veteran’s separation examination, conducted in June 1977, the scars on the left arm and left knee were documented to be present, but it was not documented that the scars were painful at that time. Additionally, the remainder of the STRs do not document that the Veteran had painful scars, nor do they document an injury to the left arm or left knee during service that would cause a new scar or cause an old scar to become painful. While the Veteran is competent to report symptoms of a cut or injury to his left knee or left arm in service and that his scars became painful in service, the Board finds the Veteran’s testimony of an additional injury in service to be less credible than the contemporaneous STRs. Additionally, the Board finds it noteworthy that the Veteran himself did not actually testify that his scars became painful in service. Rather, he testified that he had new cuts and injuries to his left arm and left knee in service. While a cut to the left arm or left knee may not have been reported at the time of the alleged injury, the Board finds the Veteran’s testimony that he obtained new scars or the argument that the scars became painful in service to be less probative, as the Veteran did not report these injuries or an increase in symptomatology at discharge from service. The June 1977 examiner documented that the Veteran had a scar on his left arm and left knee, but did not note there was more than one scar in each location, which may have been indicative of a new injury, nor did the examiner document that the Veteran reported that the scarring that was painful. The Board finds the Veteran would have likely reported any new injuries or any new symptoms related to his scars at that time if any such disability had occurred, as these scars, as well as a mole over his eye, were documented on the examination, and, as is fully addressed above, the Veteran reported multiple injuries and illnesses to medical personnel during his active service. Additionally, the Veteran signed a statement on the separation examination noting that he was aware that any defects, whether disqualifying for service or not, would be reported on the examination for the purposes of entitlement to benefits from the Veterans Administration. Presumably in signing this, the Veteran understood that the examination was an opportunity report any and all incidents or injuries in service, and the Veteran did not report symptoms of painful scars, nor did he report any other injuries to his left arm or left knee. For all the reasons laid out above, the Board finds the preponderance of the evidence is against the claims for service connection for a scar on the left arm and a scar on the left knee due to a finding that the pre-existing scars were not aggravated during service. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claims for service connection for scars on the left arm and left knee are denied. 6. Entitlement to service connection for PTSD The Veteran has provided multiple reports of a stressor to support his assertion that his PTSD was caused by his service. At the August 2019 hearing, the Veteran read into the record a June 2019 statement in which reported that while he was walking the fence line on guard duty while serving at Guantanamo Bay, he was shot at and had rocks thrown at him. He also reported an instance in which a man, woman, and two children were running towards the fence line while being shot at by Cuban soldiers. Within the statement, the Veteran wrote that the man stepped on a landmine and the woman was shot with a machine gun as she climbed the fence. He reported that he called in the shooting and that they brought the children with them but ultimately resumed patrol of the fence line. He also stated that in another instance, he shot at a tree while on guard duty because he thought he saw something threatening. He stated that he received a court martial for shooting his gun. Service connection for PTSD requires medical evidence diagnosing the disability in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the in-service stressor occurred. 38 C.F.R. § 3.304(f). The diagnosis of PTSD must comply with the criteria set forth in the American Psychiatric Association Diagnostic and Statistical manual of Mental Disorders, 5th edition, of the American Psychiatric Association (DSM-5). See 38 C.F.R. § 4.125(a), 4.130. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for PTSD. The reasons follow. Service connection for PTSD requires credible supporting evidence that an in-service stressor occurred under 38 C.F.R. § 3.304(f). Under that section, it states that PTSD may be diagnosed during service or based on specified types of claimed stressors. In this case, the STRs do not document a diagnosis of PTSD in service, and the Veteran does not contend that PTSD was diagnosed during service. Thus, § 3.304(f)(1) does not apply to this case. The Veteran’s service in Cuba at Guantanamo Bay did not include combat, which the Veteran also acknowledged at his August 2019 hearing, nor does the record document that the Veteran has an award or decoration indictive of combat, and thus, § 3.304(f)(2) does not apply. The Veteran does not contend, and the record does not support a finding, that he was a prisoner-of-war or that his claim is based on an in-service personal assault. Thus, § 3.304(f)(4) and (5) do not apply. This leaves § 3.304(f)(3), which provides that “if a stressor claimed by a veteran is related the veteran’s fear of hostile military or terrorist activity... in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran’s service, the veteran’s lay testimony alone may establish the occurrence of the claimed stressor.” In this case, the Board finds that the Veteran’s period of service at Guantanamo Bay did not involve hostile military or terrorist activity. Within the regulation, it explains that for purposes of this paragraph, “fear of hostile military or terrorist activity” means that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran’s response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror.” 38 C.F.R. § 3.304(f)(3). VA sought the command histories from July 1975 to December 1975 and from January 1976 to June 1976, during the period of time when the Veteran was stationed at Guantanamo Bay for purposes of corroborating the Veteran’s stressors. Though the Command Histories do not contain specific day-to-day reports as to what was happening on Guantanamo Bay, within each of these Command Histories, there is a section entitled, “Sequential Listing of Significant Events.” The claimed stressor that the Veteran was shot at while he patrolled the border of Guantanamo Bay, including one occasion where a man stepped on a landmine and was killed and/or a woman was shot attempting to climb the fence, leaving behind two children, involve reports of significant attacks on and around a United States military installation. The Board finds it unlikely that there is no documentation of such a significant event or events, as the Veteran claimed that he and others with whom he was performing the guard duty were shot at, which would indicate he and others were confronted with an event or circumstance that involved actual or threatened death or serious injury or a threat to the physical integrity of the Veteran and others. He also had alleged that the two children who had been accompanying the deceased adults were taken, at least temporarily, by United States personnel, to another location and that he reported the incident. The Board finds that incidents in which United States military personnel were shot at on the border of the military installation and/or an incident of a woman being killed on the fence line after helping two children over the fence, where the children were in the care of the United States, even if for a short period of time, would have been documented to some extent within the Command Histories, as such would have been a significant event. The Command Histories also have a “Narrative Summary,” which do not list events such as described by the Veteran. The Board understands that the Veteran’s representative does not believe that these incidents would have necessarily made it into the Command Histories, but that does not mean that such opinion is accurate. If Marines’ lives were threatened by being on the receiving end of gunfire, the Board finds that such would have been documented within the Command Histories. This determination involves a weighing of evidence, which is within the Board’s purview. The personnel records also do not include documentation of a court martial related the Veteran shooting his weapon inappropriately. Additionally, when the Veteran first sought treatment with VA in August 2011, a PTSD screen was performed. The Veteran was asked if he had any nightmares about it or thought about it when he did not want to, whether he had tried hard not to think about it or went out of his way to avoid situations that reminded him of it, if he had been constantly on guard, watchful, or easily startled, and whether he felt numb or detached from others, activities, or surroundings, and the Veteran answered no to every one of the questions. A review of systems was performed at that time, and the Veteran denied depression, anxiety, or changes in sleep pattern. The Veteran has subsequently claimed on multiple occasions that he never recovered from the in-service incidents, which is inconsistent with his August 2011 denials when answering the PTSD screen questions. The Board acknowledges that the Veteran has been diagnosed with PTSD based on his self-reported in-service stressors as addressed above. This shows that the criteria for a DSM-5 diagnosis of PTSD is met. However, the award of service connection for PTSD has three parts to it, one of which involves a finding of “credible supporting evidence that the claimed in-service stressor occurred.” The Board is tasked with adjudicating whether a stressor has credible supporting evidence. Thus, the VA examiner’s finding that the stressor is credible is not binding on the Board. The Board has engaged in a thorough examination of the multiple reports of the Veteran’s stressors, as well as the available records, including the results of the National Archives and Records Administration’s search. The Board does not find the evidence contained in the claims file establishes that the claimed stressor or stressors occurred. There is a relaxed standard of establishing an in-service stressor when fear of hostile military or terrorist activity exists; however, that relaxed standard does not apply to Guantanamo Bay in the latter part of 1975 or the early part of 1976, when the Veteran was present at that location. Thus, in these circumstances, there must be credible supporting evidence that the claimed in-service stressor occurred. The Veteran’s statements alone, without corroboration, cannot establish the in-service stressor. The preponderance of the evidence is against a finding that the Veteran has presented credible supporting evidence that the claimed in-service stressor or stressors occurred. Thus, the facts establishing that the Veteran has a diagnosis of PTSD based on his lay statements of a stressor during service are insufficient to establish entitlement to service connection for PTSD. The Board finds that a remand for a VA examinations or medical opinion is not warranted. McLendon, 20 Vet. App. 79. As laid out in detail above, the preponderance of the evidence is against an event, injury, or disease occurred in service, as the requirement of credible supporting evidence of an in-service stressor has not been met. For a VA examination and/or medical opinion to be warranted, all the McLendon criteria must be met, and at least one of the criteria is not met. Therefore, entitlement to a VA examination and/or medical opinion is not warranted for the service-connection claim. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for PTSD is denied.   REASONS FOR REMAND 7. – 8. Entitlement to service connection for a bilateral foot disability The Board finds an addendum opinion is necessary as it relates to the claim for service connection for a bilateral foot disability. The addendum opinions provided by the February 2012 VA examiner all rely on a finding that the Veteran was not presumed sound at the time of entrance into service. As the entrance examination does not include a notation that pes planus was documented at entry, and, rather, the entrance examination notes only a history of a right foot fracture, the addendum opinions provided are based on an inaccurate representation of the facts and are inadequate. Additionally, though the initial examination did provide a positive nexus between the foot disabilities and the Veteran’s service. On the February 2012 examination, the Veteran was diagnosed with pes planus, metatarsalgia, hammer toe, callouses, and onychomycosis. However, the examiner did not specify which of the many diagnosed foot disabilities were at least as likely as not related to service when providing an opinion. The examiner opined that a bilateral foot disability, generally, had continued since service. From this opinion it is unclear which of the diagnosed foot disabilities the examiner was suggesting were at least as likely as not related to the Veteran’s service. Additionally, the Board notes that in providing the opinion, the examiner also noted an old healed fracture of the L5 metatarsal. This injury pre-existed service as it was noted on the entrance examination and was mentioned in the rationale portion of the examination, but the examiner did not provide an explanation as to what impact this previous fracture had on the development of any of the diagnosed disabilities. Thus, the initial positive nexus opinion provided by the February 2012 examiner is also inadequate. The matters are REMANDED for the following action: Obtain an addendum opinion from an appropriate clinician. If the clinician finds that an in-person examination is warranted, an examination should be scheduled. The examiner must review the claims file, and the examiner is asked to provide a response to the following: Is any diagnosed foot disability, including pes planus, metatarsalgia, hammer toe, callouses, and onychomycosis, at least as likely as not related to an in-service injury, event, or disease? In providing this opinion, the examiner is asked to specifically comment on the positive nexus opinion provided by the February 2012 VA examiner, specifically the portion of the rationale in which the examiner raised the issue of an old healed fracture of the L5 metatarsal. The examiner is asked to note any impact the previous injury had on the development of any currently diagnosed disabilities. The examiner is asked to provide a rationale for each opinion given, including providing the medical principles and evidence relied upon for each opinion. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Keninger, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.