Citation Nr: 21009757 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 15-23 664 DATE: February 23, 2021 ORDER Entitlement to an increased evaluation in excess of 10 percent for left ankle strain with tendonitis for the period prior to July 21, 2020, is denied. Entitlement to an evaluation of 20 percent for left ankle strain with tendonitis for the period since July 21, 2020, is granted. Entitlement to a compensable evaluation for chronic fatigue syndrome (CFS) prior to September 12, 2018, is denied. Entitlement to an increased evaluation in excess of 40 percent for chronic fatigue syndrome (CFS) for the period since September 12, 2018, is denied. Entitlement to an increased evaluation in excess of 10 percent for recurrent sinusitis is denied. Entitlement to service connection for anxiety is denied. Entitlement to service connection for depression is denied. Entitlement to service connection for a low back disability is denied. Entitlement to service connection for diabetes mellitus is denied. Entitlement to service connection for cataracts as secondary to service-connected disabilities is denied. Entitlement to service connection for diabetic neuropathy of the bilateral lower extremities is denied. Entitlement to service connection for obstructive sleep apnea (OSA) is denied. REMANDED Entitlement to service connection for flat feet is remanded. Entitlement to irritable bowel syndrome (IBS) as secondary to service-connected disabilities is remanded. FINDINGS OF FACT 1. For the period prior to July 21, 2020, the Veteran’s left ankle strain with tendonitis was at worse manifested by moderate limitation with plantar flexion to 25 degrees and dorsiflexion to 10 degrees. 2. Resolving reasonable doubt, for the period since July 21, 2020, the Veteran’s left ankle strain with tendonitis was evidenced at worse by 5 degrees of dorsiflexion, with evidence of painful motion, and more closely approximates marked limitation of motion of the left ankle. 3. Prior to September 12, 2018, the Veteran’s chronic fatigue syndrome (CFS) has not manifested with a total period of incapacitation of at least one week; or, the requirement of control by continuous medication at any time during the initial rating period on appeal. 4. Since September 12, 2018, the Veteran’s chronic fatigue syndrome (CFS) was manifested by no worse than signs and symptoms that were nearly constant and restricted routine daily activities to 50 to 75 percent of the pre-illness level, or with signs and symptoms that waxed and waned, without resulting periods of incapacitation. 5. The Veteran’s recurrent sinusitis has not been shown to be manifested by three or more incapacitating episodes per year requiring prolonged antibiotic treatment, or more than six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge. 6. The evidence does not show that depressive disorder or anxiety disorder is separate and distinct from the Veteran’s service-connected PTSD. 7. The preponderance of the evidence is against a finding that the Veteran’s low back disability is related to the Veteran’s active duty service. 8. The preponderance of the evidence is against a finding that the Veteran’s diabetes mellitus is related to the Veteran’s active duty service. 9. The Veteran’s cataracts are not related to service and are not caused or aggravated by a service-connected disability. 10. The preponderance of the evidence is against a finding that the Veteran’s diabetic neuropathy of the bilateral lower extremities is related to the Veteran’s active duty service. 11. The preponderance of the evidence is against a finding that the Veteran’s obstructive sleep apnea is related to the Veteran’s active duty service. CONCLUSIONS OF LAW 1. For the period prior to July 21, 2020, the criteria for a rating in excess of 10 percent for the Veteran’s left ankle strain with tendonitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5271. 2. For the period beginning July 21, 2020, the criteria for a 20 percent rating for the Veteran’s left ankle strain with tendonitis have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5271. 3. For the period prior to September 12, 2018, the criteria for a compensable evaluation for the Veteran’s CFS have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 6354. 4. For the period since September 12, 2018, the criteria for a rating in excess of 40 percent for the Veteran’s CFS have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 6354. 5. The criteria for a rating in excess of 10 percent for sinusitis have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.96, 4.97, Diagnostic Code (DC) 6512. 6. The criteria for entitlement to separate service connection for anxiety, have not been met. 38 U.S.C. §§ 1113, 5107(b); 38 C.F.R. §§ 3.303. 7. The criteria for entitlement to separate service connection for depression, have not been met. 38 U.S.C. §§ 1113, 5107(b); 38 C.F.R. §§ 3.303. 8. The criteria for service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.159, 3.303. 9. The criteria for service connection for diabetes mellitus have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.159, 3.303. 10. The criteria for service connection for cataracts have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.159, 3.303. 11. The criteria for service connection for diabetic neuropathy of the bilateral lower extremities have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.159, 3.303. 12. The criteria for service connection for obstructive sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in active duty service with the Navy from December 1989 to April 1993 to include service in Southwest Asia. This matter is on appeal from January 2013 and June 2016 rating decisions. The Veteran was afforded a hearing before the undersigned Judge in September 2018. A transcript of the hearing has been associated with the claims record. In an August 2019 Board decision, the Board denied entitlement to service connection to IBS as secondary to service-connected disabilities. The Board also remanded the issues on appeal for additional development. The Veteran appealed his denial to the Court of Appeals for Veterans Claims (CAVC or the Court). The Court, in June 2020, issued a joint motion for partial remand (JMPR) to vacate and remanded the issue back to the Board for re-adjudication. The Board notes that during pendency of the appeal, a September 2020 rating decision granted a 40 percent evaluation for the Veteran’s chronic fatigue syndrome (CFS) effective from September 12, 2018, and service connection for posttraumatic stress disorder. As the Veteran has not indicated satisfaction with the increased evaluation, the Board finds the issue of entitlement to an increased rating for the Veteran’s CFS remains on appeal. AB v. Brown, 6 Vet. App. 35, 39 (1993). As such, the Board has recharacterized the issues on appeal as entitlement to compensable evaluation for chronic fatigue syndrome (CFS) prior to September 12, 2018; and an increased evaluation in excess of 40 percent for the Veteran’s CFS from September 12, 2018. Increased Rating A disability rating is determined by the application of VA’s Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Board will consider whether separate ratings may be assigned for separate periods of time based on the facts found, a practice known as “staged ratings.” Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Left Ankle disability The Veteran is currently service connected for a left ankle strain with tendonitis evaluated at 10 percent under Diagnostic Code 5271. When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). A disability of the musculoskeletal system is primarily the inability, due to damage or infection in parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to the absence or deformity of structures or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by the visible behavior in undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. § 4.40. With respect to joints, in particular, the factors of disability reside in reductions of normal excursion of movements in different planes. Inquiry will be directed to more or less than normal movement, weakened movement, excess fatigability, incoordination, pain on movement, swelling, deformity or atrophy of disuse. 38 C.F.R. § 4.45. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. Under 38 C.F.R. § 4.59, “the trigger for a minimum disability rating is an actually painful, unstable, or malaligned joint.” 38 C.F.R. § 4.59 speaks to both painful motion of joints and actually painful joints. Petitti v. McDonald, 27 Vet. App. 415 (2015). For purposes of 38 C.F.R. § 4.59, objectively confirmed limitation of motion must be corroborated by a person, either lay or medical professional, and may not be satisfied by the Veteran’s own observations. Id. Limitation of motion of the ankle is rated under Diagnostic Code 5271 which provides for a 10 percent rating for restricted motion that is moderate. A maximum 20 percent rating is warranted for limitation of motion of the ankle that is marked. 38 C.F.R. § 4.71a , Diagnostic Code 5271. Normal ranges of motion of the ankle are dorsiflexion from zero degrees to 20 degrees, and plantar flexion from zero degrees to 45 degrees. 38 C.F.R. § 4.71a, Plate II. The terms “moderate” and “marked” are not defined in VA regulations, and the Board must arrive at an equitable and just decision after having evaluated the evidence. 38 C.F.R. § 4.6. While the schedule of ratings does not provide any information as to what manifestations constitute “moderate” or “marked” limitation of ankle motion, guidance can be found in VBA’s M21-1 Adjudication Procedures Manual. Specifically, the M21-1 states that moderate limitation of ankle motion is present when there is less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion, while marked limitation of motion is demonstrated when there is less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion. See VBA Manual M21-1, III.iv.4.A.3.k. In a September 2010 VA examination, the Veteran reported symptoms of intermittent and moderate pain and swelling. The Veteran stated experiencing weekly flareups aggravated by exercising. The Veteran stated that his symptoms resulted in limitation and 25 percent reduction in his function; the Veteran stated that he could walk at most 15 to 20 minutes and from 1 to 2 miles. Upon physical examination, the Veteran’s dorsiflexion was measured at 10 degrees and his plantar flexion was measured at 25 degrees. X-ray tests of his foot found normal views of his left ankle. In a May 2011 vocational rehabilitation report, the Veteran reported that he had missed work in January and February 2011 due to his left ankle. The Veteran stated that he wears an ankle brace due to an unstable ankle joint and had issues with prolonged standing and walking; using stairs; squatting; and swelling. The Veteran was afforded a June 2016 VA examination. The Veteran reported symptoms of constant moderately severe left ankle pain that worsened with exercise and intermittent swelling. The Veteran reported flareups whenever he attempted to exercise but did not report any functional loss. Upon physical examination, the Veteran’s range of motion (ROM) was measured at 20 degrees dorsiflexion and 40 degrees plantar flexion. Pain was noted on all motions but no evidence of pain with weight bearing. The Veteran was able to perform repetitive testing without additional loss of motion. The Veteran demonstrated full strength with no evidence of ankylosis. X-ray testing found mild soft tissue swelling but no evidence of acute significant abnormality. At the Veteran’s September 2018 hearing, the Veteran testified that his left ankle had worsened. The Veteran stated that he walks with a limp, experienced increased pain, and developed swelling while jogging. The Veteran noted that due to his work as an in-school suspension (ISS) instructor, he needed to “keep appearances at his work to not look weak” so that the students would not take advantage of him. The Veteran noted problems while jogging with increased pain and nightly swelling. The Veteran was afforded a September 2019 VA examination. The Veteran reported symptoms aggravated by weather changes, extended weight-bearing, and uneven terrain. The Veteran reported his most recent flareup occurred with increased pain lasting for two days. The Veteran reported functional impairment where he would have difficulty with uneven terrain and extensive weight bearing without breaks on his left side. Upon physical examination, the Veteran’s range of motion (ROM) was measured at 15 degrees dorsiflexion and 30 degrees plantar flexion. Pain was noted on all motions but no evidence of pain with weight bearing. The Veteran was able to perform repetitive testing without additional loss of motion. The examiner found the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss with flareups or repetitive use over time. The Veteran demonstrated full strength with no evidence of ankylosis. X-ray testing found no evidence of acute fractures or dislocation or significant degenerative changes. The Veteran was afforded a July 21, 2020 VA examination. The Veteran reported symptoms of pain with weight bearing. The Veteran reported flareups when he is on his feet a lot; the Veteran stated that his left ankle would swell or “sometimes it gives out.” The Veteran reported functional impairment where he wears a brace at work and does no running or hiking. Upon physical examination, the Veteran’s range of motion (ROM) was measured at 10 degrees dorsiflexion and 40 degrees plantar flexion. Pain was noted on all motions. The examiner found evidence of pain with weight bearing. However, the examiner also noted that passive range of motion for the left ankle could not be performed or otherwise medically appropriate to test. The Veteran was able to perform repetitive testing without additional loss of motion. The examiner found the examination was medically consistent with the Veteran’s statements describing functional loss with flareups or repetitive use over time. The examiner estimated the Veteran’s range of motion during flareups to be at 5 degrees dorsiflexion and 30 degrees plantar flexion. The Veteran demonstrated full strength with no evidence of ankylosis. X-ray testing found negative findings other than soft tissue swelling. The examiner also found the Veteran with evidence of left side Achilles tendonitis or tendon rupture with symptoms of aching and stiffness. After review of the evidence of record, the Board finds the medical evidence is against a finding for an evaluation in excess of 10 percent for the Veteran’s left ankle disability prior to July 21, 2020. VA examinations held in September 2010, June 2016 and September 2019 did not find that the Veteran has ever had dorsiflexion of less than 5 degrees or plantar flexion of less than 10 degrees. There was no astragalectomy, malunion, joint instability, or ankylosis found. However, after review of the evidence of record and resolving reasonable doubt, the Board finds that a rating of 20 percent evaluation of the Veteran’s left ankle disability is warranted from July 21, 2020. In the July 2020 VA examination, the examiner estimated the Veteran’s range of motion during flareups to be at 5 degrees dorsiflexion with reported symptoms of swelling and instability. As such, the Board finds that these symptoms more closely approximate marked severity, thus warranting a rating of 20 percent under DC 5271 from July 21, 2020. Under the circumstances of this case, and with resolution of all reasonable doubt in the Veteran’s favor, the Board finds that a 20 percent evaluation of the Veteran’s chronic strain of the left ankle is warranted from January 1, 2008 to August 21, 2017. However, the Board does not find the evidence of record shows the Veteran’s left ankle disability meets or approximates the criteria for an evaluation in excess of 20 percent for the period since July 21, 2020. The Board notes that the Veteran’s evaluation of 20 percent under DC 5271 is the maximum rating allowed under this diagnostic code. Alternative or additional ratings are available for ankylosis, malunion of the os calcis or astragalus, a history of astragalectomy, or the functional equivalent thereof. In the absence of any findings of ankylosis in the Veteran’s left ankle, evidence of malunion of the os calcis or astragalus, or surgery for an astragalectomy those criteria are not applicable to this case. Review of the evidence of record to include the VA examinations does not show documentation of malunion of the os calcis or astragalus, surgery for an astragalectomy, or ankylosis of the left ankle. The September 2010, June 2016, September 2019 and July 2020 examiners did not find ankylosis of the left ankle. The Board also finds that there is no basis for the assignment of any higher rating based on consideration of any of the factors addressed in 38 C.F.R. §§ 4.40, 4.45 and DeLuca, 8 Vet. App. at 204-07. The competent medical evidence reflects that the assigned 20 percent properly compensates the Veteran for the extent of functional loss resulting from any such symptoms. The Board acknowledges that the Veteran had pain, swelling, weakened movement and less movement than normal. This is documented in the lay and medical evidence. Furthermore, the Board again accepts that the Veteran has functional impairment, pain and limited motion as demonstrated by the VA examinations. See DeLuca, supra. The Board further finds that the Veteran’s own reports of symptomatology to be credible. However, neither the lay nor medical evidence reflects the functional equivalent of impairment required for an evaluation in excess of 20 percent. The Board notes that the July 2020 VA examination for the left ankle found pain with weight bearing but did not include passive range of motion and did not specify range of motion with and without weight-bearing. See Correia v. McDonald, 28 Vet. App. 158 (2016). However, generally, active range of motion testing produces more restrictive results than passive range of motion testing, in that passive range of motion testing requires the physician to force the joint through its motions. There is no indication that the range of motion testing in these examinations was performed other than on weight-bearing. Therefore, there is no prejudice to the Veteran in relying on these examinations that involved active range of motion testing because such results tend to produce the “worst case scenario” of impairment and thus would tend to support the highest possible rating.” The Board acknowledges the Veteran’s statements with regard to the severity of his left ankle. The Veteran is competent to report on factual matters of which he had firsthand knowledge, e.g., experiencing limitation of motion in his left ankle. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). He is competent to provide such statements, and the Board finds that the Veteran’s statements are credible. The Veteran’s reported symptomatology has been noted in the rating decisions above, and the Board has considered the Veteran’s reports with respect to pain in evaluating his assigned ratings. With respect to the Rating Schedule, the criteria set forth therein generally require medical expertise where the types of findings required are not readily observable by a lay person. Therefore, the objective medical findings provided by the Veteran’s VA examination reports have been accorded greater probative weight. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (“[t]he probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches... the credibility and weight to be attached to these opinions [are] within the province of the adjudicator.”). The Board is mindful of the provisions under 38 C.F.R. § 3.321, which provide for consideration of the assignment of an extra-schedular disability rating for limited cases where the evidence shows an exceptional disability that is contemplated adequately by the rating criteria. Nonetheless, such consideration is not warranted by the facts of this case. 38 C.F.R. § 3.321; Thun v. Peake, 22 Vet. App. 111 (2008). Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating evaluation in excess of 10 percent for the Veteran’s left ankle for the period prior to July 21, 2020; but a 20 percent evaluation is warranted for the period since July 21, 2020. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Chronic Fatigue Syndrome (CFS) The Veteran is currently service connected for CFS with a noncompensable rating effective from June 16, 2010 to September 12, 2018; and a 40 percent evaluation since September 12, 2018 under diagnostic code 6354. Under DC 6354, a 10 percent disability rating is granted for symptoms that wax and wane but result in periods of incapacitation of at least one but less than two weeks total duration per year; or symptoms controlled by continuous medication. A 20 percent disability rating evaluation is assigned for symptoms which are nearly constant and restrict routine daily activities by less than 25 percent of the pre-illness level, or; which wax and wane, resulting in periods of incapacitation of at least two but less than four weeks total duration per year. A 40 percent disability rating is assigned for symptoms which are nearly constant and restrict routine daily activities to 50 to 75 percent of the pre-illness level, or; which wax and wane, resulting in periods of incapacitation of at least four but less than six weeks total duration per year. A 60 percent disability rating is assigned for symptoms which are nearly constant and restrict routine daily activities to less than 50 percent of the pre-illness level, or; which wax and wane, resulting in periods of incapacitation of at least six weeks total duration per year. A maximum, 100 percent, disability rating is assigned for symptoms which are nearly constant and so severe as to restrict routine daily activities almost completely and which may occasionally preclude self-care. Id. For the purpose of rating chronic fatigue under DC 6354, the condition will be considered incapacitating only while it requires bed rest and treatment by a physician. Note, 38 C.F.R. § 4.88b, DC 6354. In the Veteran’s September 2010 VA examination, the Veteran reported a history of fatigue and experiencing feelings of unrest after sleeping. The Veteran noted no change in fatigue after exercise. The Veteran did not report any periods of incapacitation or whether he was taking continuous medication for treatment of symptoms. In a May 2011 vocational rehabilitation report, the Veteran described limitations from his CFS, stating that he was sleepy during the day with no helpful treatment and had sometimes fallen asleep at work before with poor sleep. In a December 2012 sleep medicine note, the Veteran reported that he had trouble staying awake during the day along with difficulty falling asleep and maintaining sleep. The Veteran was assessed with sleep disturbance most likely due to chronic sleep deprivation “symptomatic of multiple other sleep problems.” The Veteran was afforded a June 2016 VA examination. The Veteran reported symptoms of daytime sleepiness. The examiner found the Veteran did not require continuous medication to control his CFS. The examiner did not find that debilitating fatigue that reduced the Veteran’s daily activity level to less than 50 percent of pre-illness levels. The examiner found the Veteran with symptoms of sleep disturbance. No cognitive impact or impairment was found attributable to CFS. The examiner did find the Veteran’s symptoms waxed and waned but found no evidence of restriction of routine daily activities compared to pre-illness levels or periods of incapacitation. At the Veteran’s September 2018 hearing, the Veteran testified that he found himself falling asleep at work a lot of times and stated that this would happen three to four times a week. The Veteran stated that he tried to treat this by staying active and drinking energy drinks. The Veteran was afforded a September 2019 VA examination. The Veteran reported that he was not receiving treatment for his condition at this time and the examiner found the Veteran did not require continuous medication to treat his condition. The examiner found the Veteran had debilitating fatigue that had reduced his daily activity level to less than 50 percent for at least 6 months or longer. The examiner found the Veteran with symptoms of low grade fever described as a daytime sensation of warmth on the Veteran’s forehead with occasional low fever; generalized muscle aches independent from exercise; occasional fatigue lasting more than 24 hours after exercise; headaches; migratory joint pain that would sometimes occur in the knees, elbow and hips; sleep disturbance; and increased perspiration. The examiner found the Veteran’s CFS did not result in cognitive impairment. The examiner also found the Veteran’s symptoms restricted daily activities from 50 to 75 percent of his pre-illness level. No periods of incapacitation were found. After review of the evidence, the Board finds the evidence does not support a finding to assign a compensable evaluation for the Veteran’s CFS for the period from June 16, 2010 to September 12, 2018; and against a increased evaluation in excess of 40 percent for the period since September 12, 2018. As noted above DC 6354 provides a 10 percent disability rating is for symptoms that wax and wane but result in periods of incapacitation of at least one but less than two weeks total duration per year; or symptoms controlled by continuous medication. Review of the period from June 16, 2010 to September 12, 2018 to include the VA examinations held in September 2010 and June 2016 do not show the medical evidence supports a finding that the Veteran had symptoms controlled by continuous medication or periods of incapacitation of at least one but less than two weeks duration per year. The Veteran complained of falling asleep at work several times during the week, however the Veteran did not report missing time due to his CFS; as such, the reported symptoms itself was not indicative of incapacitation as defined under the applicable rating criteria and the Note to Diagnostic Code 6354. As such, the Board finds the Veteran’s CFS has more nearly approximated the assigned noncompensable rating for the period from June 16, 2010 to September 12, 2018. 38 C.F.R. §§ 4.1, 4.31. For the period from September 12, 2018, the Board finds the evidence of record is against a finding for an increased evaluation in excess of 40 percent. As noted above, DC 6354 provides a 60 percent disability rating for signs and symptoms of CFS that are nearly constant and restrict routine daily activities to less than 50 percent of the pre-illness level, or signs and symptoms that wax and wane, resulting in periods of incapacitation of at least six weeks total duration per year. Review of the period from September 12, 2018 to include the most recent VA examination in September 2019 does not show the Veteran’s CFS has been manifested by no worse than signs and symptoms that are nearly constant which restrict his routine daily activities to less than 50 percent of his pre-illness level, or with signs and symptoms that wax and wane, resulting in periods of incapacitation of at least six weeks in total duration per year. While the Veteran generally contends that a higher initial rating is warranted for his CFS disability, his lay assertions are of less probative value than the objective medical evidence of record. See Jandreau, 492 F.3d at1376-77. As such, the Board finds that the preponderance of the evidence weighs against a finding of a compensable rating for the Veteran’s CFS the period June 16, 2010 to September 12, 2018, and against an increased rating in excess of 40 percent since September 12, 2018. Sinusitis The Veteran is currently service connected for recurrent sinusitis evaluated at 10 percent under Diagnostic Code 6512. Respiratory disorders are rated under Diagnostic Codes 6600 through 6817 and 6822 through 6847. Ratings under those diagnostic codes will not be combined with each other. Rather, a single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher rating only where the severity of the overall disability warrants such elevation. 38 C.F.R. § 4.96 (a). Diagnostic Codes 6510 through 6514 pertain to various types of sinusitis, each of which is rated pursuant to a General Rating Formula for Sinusitis. This general rating formula for sinusitis applies in all circumstances in which VA is to evaluate the severity of sinusitis, no matter what the particular diagnosis, and is the most appropriate criteria by which to assess any form of sinusitis. Under the General Rating Formula for Sinusitis, a noncompensable evaluation is warranted when sinusitis is detected by x-ray only. A 10 percent rating requires one or two incapacitating episodes per year requiring prolonged (lasting from four to six weeks) antibiotic treatment; or three to six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting. A 30 percent rating requires three or more incapacitating episodes per year requiring prolonged (lasting from four to six weeks) antibiotic treatment; or, more than six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting. A 50 percent evaluation requires chronic osteomyelitis following radical surgery, or; near constant sinusitis characterized by headaches, pain, and tenderness of affected sinus, and purulent discharge or crusting after repeated surgeries. See 38 C.F.R. § 4.97, Diagnostic Code 6512, General Rating Formula for Sinusitis. An incapacitating episode means one that requires bed rest and treatment by a physician. See Id. The Board emphasizes that under the provisions of 38 C.F.R. § 4.96 (a), ratings under Diagnostic Codes 6512 (sinusitis) and 6522 (rhinitis) will not be combined with each other. This is because they are coexisting respiratory conditions with overlapping symptomatology. Rather, a single rating will be assigned under the diagnostic code which reflects the predominant disability with elevation to the next higher rating only where the severity of the overall disability warrants such elevation. Id. On this issue, with regard to Diagnostic Codes 6600 and 6646, assigning separate ratings under these diagnostic codes would constitute pyramiding, contrary to the provisions of 38 C.F.R. § 4.14. In effect, the Veteran is not entitled to separate and additional ratings under these diagnostic codes for his service-connected sinusitis, as manifestations of a disability under multiple diagnoses (i.e., pyramiding) is to be avoided under 38 C.F.R. § 4.14. Separate ratings cannot be established. However, in rating his service-connected sinusitis, application of 38 C.F.R. § 4.14 does not prohibit the Board from comparing the rating criteria for both Diagnostic Codes 6600 and 6846 and considering which provides a higher evaluation based on the manifestations of the disability. See Butts v. Brown, 5 Vet. App. 532 (1993) (choice of diagnostic code should be upheld if it is supported by explanation and evidence). Therefore, the Board will evaluate the Veteran’s sinusitis under the diagnostic code that will provide the most favorable rating, ever mindful not to pyramid and overly compensate him for the same symptom. See, e.g., Esteban v. Brown, 6 Vet. App. 259, 261 (1994). At the Veteran’s September 2010 VA examination, the examiner found the Veteran’s sinusitis resulted in 3 non-incapacitating episodes in the past 12 months. The examiner noted the Veteran had received treatment with a prescription for antibiotics but did not indicate the length of treatment and noted the Veteran was not under current treatment. In a May 2011 vocational rehabilitation report, the Veteran stated that his sinusitis had symptoms of sinus pain and pressure. The Veteran stated that he suffers from frequent sinus infection and received treatment with antibody prescriptions. The Veteran further reported that he missed work in February 2011 due to headaches and flu-like symptoms. Review of the medical treatment record shows in December 2011 the Veteran complained of 2 days of sinus congestion with symptoms of headache, drainage and slight cough. The treating provider noted the Veteran with a history of sinus infection during weather changes and assessed the Veteran with acute sinusitis. The Veteran was prescribed with a nasal spray and instructed to followup in March 2012. In a June 2012 statement from the Veteran’s wife, the wife stated that the Veteran’s sinus problems kept him incapacitated on a regular basis. The Veteran’s wife stated that the Veteran’s sinus problems would cause headaches that would be severe enough to make him stay home from work; this in turn would cause the wife to miss work because she would need to transport the Veteran for medical attention. The Veteran’s wife stated the Veteran’s sinus condition would cause him breathing difficulty and then stress on a regular basis. The Veteran’s wife noted that the Veteran’s migraines would sometimes be so severe that “the whole household is forced to be silent during his attack episodes.” In a separate June 2012 statement, the Veteran stated that his sinus condition had worsened. The Veteran stated that his sinus condition was continuous without relief and resulted in headaches that would incapacitating him for two to three days at a time twice a month. In a January 2013 statement submitted before his VA examination, the Veteran stated that he had been incapacitated at least 6 to 8 times a year for the past couple years due to sinus attacks and headaches. The Veteran stated that these episodes rendered him unable to function or work and cause him to become ineffective and call in sick. The Veteran reported experiencing constant headaches of mild to severe pain depending on the weather and intensity of his sinus episodes. The Veteran was afforded a January 2013 VA examination. The Veteran reported symptoms of near constant pressure adjacent to the tip of his nose; post-nasal drip; and two clear-cut episodes of acute sinusitis. The examiner diagnosed the Veteran with sinusitis and allergic rhinitis. The examiner found the Veteran’s sinusitis to affect his maxillary and ethmoid sinuses. The examiner found the Veteran with symptoms of episodes of sinusitis and headaches. The examiner found the Veteran suffered from two non-incapacitating episodes in the past 12 months and found no evidence of any incapacitating episodes requiring prolonged antibiotic treatment. The examiner also found the Veteran with allergic rhinitis with greater than 50 percent obstruction of the nasal passage on both sides due to rhinitis. No evidence of complete obstruction or nasal polyps was found. Diagnostic testing found mild sinusitis of the bilateral maxillary and anterior ethmoid sinuses. The examiner found the Veteran’s sinusitis did not impact his ability to work. In a January 2014 notice of disagreement (NOD), the Veteran stated that his condition has steadily worsened with no relief from his continuous sinus condition. The Veteran stated that he continued to suffer from headaches and miss work due to incapacitating headaches and constant treatment for recurring sinus infection. At the Veteran’s September 2018 hearing, the Veteran testified his sinusitis had worsened. The Veteran stated that he had problems with migraines and headaches with his sinuses and noted that these problems would occur together most of the time. The Veteran stated that his condition has affected his employment and ability to go to work; the Veteran testified that he would be debilitated or incapacitated two to three days of the week. The Veteran stated that he generally tries to sleep it off or take over the counter medication for treatment; the Veteran noted that he had been prescribed medication but it would become ineffective later and he did not want to become addicted to any medication. The Veteran was afforded a September 2019 VA examination. The Veteran reported chronic symptoms with intermittent infections treated by nasal spray, sinus rinse and over the counter medication. The examiner found sinusitis that affected the Veteran’s maxillary, frontal and ethmoid sinuses. The examiner found the Veteran with symptoms of episodes of sinusitis, headaches, pain of the affected sinus, tenderness, purulent discharge, and crusting. The examiner found the Veteran with 4 episodes of non-incapacitating episodes in the past 12 months. The examiner did not find the Veteran to have experienced any incapacitating episodes of sinusitis requiring prolonged antibiotic treatment. The examiner found the Veteran did not have permanent hypertrophy of the nasal turbinates, nasal polyps, any granulomatous conditions, or chronic laryngitis. The Veteran did not have vocal cord paralysis or any other pharyngeal or laryngeal conditions. There were no other pertinent physical findings, complications, conditions, signs, and/or symptoms, to include scars, related to his condition. There were no significant diagnostic test findings and/or results. The examiner found that the Veteran’s conditions did not impact his ability to work. After review of the evidence of record, the Board finds that an evaluation in excess of 10 percent for the Veteran’s sinusitis is not warranted. As noted above, an increased 30 percent disability rating is warranted under Diagnostic Code 6512 when there are three or more incapacitating episodes per year of sinusitis requiring prolonged (lasting four to six weeks) antibiotic treatment, or; more than six non-incapacitating episodes per year of sinusitis characterized by headaches, pain, and purulent discharge or crusting. The evidence does not support the Veteran receiving a rating greater than 10 percent for sinusitis because there is no medical evidence of three or more incapacitating episodes per year of sinusitis requiring prolonged antibiotic treatment, or; more than six non-incapacitating episodes per year characterized by headaches, pain, and purulent discharge or crusting necessary for a 30 percent rating under the applicable criteria. Although the Veteran has submitted statements and testimony that his sinusitis has caused him to miss work or become severe enough to be debilitating, none of the VA examiners found the evidence to support a finding that the reported episodes to rise to the level of a non-incapacitating or incapacitating episode of sinusitis. The Board has considered whether separate and/or higher disability ratings are warranted under any other potentially applicable DCs pertaining to diseases of the ear, nose, and throat. The Veteran did not have scars relate to his condition. Therefore, a separate rating is not warranted under DCs 6502 or 6504. Additionally, the Veteran did not have vocal cord paralysis or any other pharyngeal or laryngeal conditions. Therefore, a higher and/or separate rating is not warranted under DCs 6515-6521. The Board notes that examinations and medical records have shown that the Veteran has experienced symptoms of rhinitis as well. Allergic rhinitis is evaluated under Diagnostic Code 6522. A 10 percent rating is warranted for allergic rhinitis without polyps, but with a greater than 50 percent obstruction of nasal passage on both sides or one side. Bacterial rhinitis is evaluated under Diagnostic Code 6523. A 10 percent rating is warranted for bacterial rhinitis with permanent hypertrophy of turbinates and with greater than 50 percent obstruction of nasal passage on both sides or complete obstruction on one side. The Board notes at the January 2013 VA examination, the examiner found that the Veteran’s rhinitis manifested with a greater than 50 percent obstruction of nasal passage on both sides or one side. The Veteran did not have any polyps, or permanent hypertrophy of the nasal turbinates. The examination found the Veteran with allergic rhinitis. However, the noted symptoms would warrant only a 10 percent rating under Diagnostic Codes 6522 and therefore assigning a separate rating would be considered impermissible pyramiding pursuant to 38 C.F.R. § 4.96 (a) as addressed above. Therefore, while both conditions were present and warranted a 10 percent rating under their respective DCs, 38 C.F.R. § 4.96 (a) prohibits the assignment of separate ratings. Rather, the conditions will be rated under the predominant disability, which, during such portion of the appeal period, may be considered either sinusitis or rhinitis as they are equally severe, and elevation to the next higher evaluation will only be warranted when the severity of the overall disability warrants such evaluation. In the instant case, the Board finds that such requirement is not met. The Board notes the examiner did not distinguish which signs and symptoms of the Veteran’s service-connected sinusitis apart from his non-service-connected rhinitis. When the signs and symptoms of a service-connected disability cannot be distinguished from those attributable to a non-service-connected condition, all signs and symptoms that cannot be distinguished must be attributed to the service-connected condition. Mittleider v. West, 11 Vet. App. 181, 182 (1998). As such, the Board has considered all the Veteran’s respiratory symptoms in continuing to deny a rating greater than 10 percent. The Board will not attempt to distinguish which condition is the cause of each respiratory symptom the Veteran experiences. The Board has considered the Veteran and his representative’s statements regarding the severity of the Veteran’s sinusitis. While the Veteran is competent to report symptoms such as sinus pain, headaches and discharge, he has not described episodes of sinusitis of sufficient severity and frequency to warrant an increased evaluation. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). As such, the VA treatment record and the VA examination reports of record do not indicate or otherwise suggest that the Veteran’s sinusitis warrants an increased evaluation. Accordingly, the frequency and severity of the Veteran’s episodes of sinusitis does not warrant a higher rating in excess of the currently assigned 10 percent rating for sinusitis or for a compensable rating during the appeal period. Therefore, the preponderance of the evidence is against the claim for a rating in excess of 10 percent for the Veteran’s service-connected sinusitis. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be established for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (a). Also, a disability that is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). To prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Certain chronic diseases, including arthritis, may be service connected if manifested to a degree of 10 percent disabling or more within one year after separation from service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. A layperson is competent to report on the onset and continuity of his or her current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno, supra (distinguishing between competency (“a legal concept determining whether testimony may be heard and considered”) and credibility (“a factual determination going to the probative value of the evidence to be made after the evidence has been admitted”). When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Entitlement to separate service connection for anxiety and depression The Veteran claims his anxiety and depression are related to his active duty service. As noted above, a September 2020 rating decision granted service connection to PTSD based upon findings of depressed mood and anxiety. Regarding the issue of service connection for depression or anxiety separately, PTSD, depressive, and anxiety disorders are all rated under the same criteria. In this case, the depression and anxiety symptoms substantially overlap with the PTSD symptoms. At the May 2020 VA examination for PTSD, the Veteran’s PTSD symptoms included depressive mood and anxiety. The examiner further found that separate diagnoses for depressive and anxiety disorder were not warranted as they were considered symptoms of the Veteran’s PTSD. Given that the Veteran’s depressive and anxiety symptoms are being compensated through his service-connected PTSD, to rate the Veteran’s depression and anxiety disorder again separately would be considered pyramiding. The evaluation of the same disability under various diagnoses, known as pyramiding, is to be avoided. Both the use of manifestations not resulting from service-connected disease or injury in establishing the service-connected evaluation, and the evaluation of the same manifestation under different diagnoses are to be avoided. 38 C.F.R. § 4.14. Notwithstanding the above, VA is required to provide separate evaluations for separate manifestations of the same disability which are not duplicative or overlapping. See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). If it is not possible to distinguish between the respective symptoms because they are so intertwined, then the symptoms will be attributed to the service-connected disability. See 38 C.F.R. §§ 3.102, 4.14; Mittleider v. West, 11 Vet. App. 181, 182 (1998). The Board determines that separate service connection and evaluation for depression and anxiety is not warranted since it will be encompassed by the rating assigned for the Veteran’s service-connected PTSD. As such, the Board determines that separate service connection for depression and anxiety is not warranted in this matter. Low back disability The Veteran contends that his low back disability is related to his active duty service. Review of the medical treatment record show complaints and treatments for low back pain. In a June 2016 VA examination, the Veteran was diagnosed with degenerative arthritis of the spine. As such, the Board finds the Veteran with a current disability. Review of the Veteran’s service treatment records (STRs) do not show any complaints, treatments or diagnoses relating to a low back disability. The Veteran at his March 1993 separation examination did not report any issues with back pain, joint deformity, or arthritis. Review of the medical treatment record shows in January 2005 the Veteran complained of lower back and abdominal pain. In a September 2010 VA examination, the Veteran reported low back pain with no flareups. X-rays of the back were normal, and no diagnosis was given. In April 2015, an MRI of the Veteran’s lumbar spine for low back pain found multilevel degenerative changes. The Veteran complained of low back pain and bilateral leg pain for the past 3 months. The treating provider gave an impression of lumbar spondylosis and facet arthrosis. In May 2015 the Veteran received a steroid shot for his back pain. The Veteran would be seen for various visits for physical therapy to treat his back pain. In a December 2015 statement from the Veteran’s wife, she described the Veteran’s various medical issues to include back pain but did not discuss how they were related to the Veteran’s active duty service. The Veteran was afforded a June 2016 VA examination. The Veteran was diagnosed with degenerative arthritis of the spine. The Veteran stated that in 1991 he slipped on a catwalk while in the Navy and fell on his back, injuring it. The Veteran described current symptoms of daily moderately severe low back pain with stiffness and night pain radiating down his legs. The examiner stated that this disease was a clear and specific etiology and disease and that it was not likely that it was related to a specific exposure event during the Veteran’s service in Southwest Asia. The examiner did not opine whether it was related to the rest of his active duty service. At the Veteran’s September 2018 hearing, the Veteran testified that his low back disability resulted from his duties in service where he was required to carry heavy equipment and chains to secure helicopters when they landed, resulting in back pain. In September 2019 a VA medical addendum opinion was obtained. The examiner noted that a review of available records to include the Veteran’s testimony was done. The examiner found it was less likely than not that the Veteran’s low back disability was incurred in or caused by the Veteran’s claimed in-service injury, event or illness. The examiner noted the Veteran’s active duty service period from December 1989 to April 1993 and stated that the Veteran’s reported duties in carrying heavy equipment in service would have resulted the Veteran in “likely experienced back pain requiring evaluation and treatment for a progressive chronic back pain during active duty.” The examiner stated while the Veteran’s previous reports and contentions related to his back disability could be deemed credible, the examiner also found there were contradictions when compared to the Veteran’s military record. The examiner noted the Veteran had previous reported that he fell in 1991 while in the Navy. The examiner found review of the military to include medical examinations in January 1990, November 1990 and his March 1993 separation examination reported all negative responses to recurrent back pain and findings of a normal spine. The Board acknowledges the Veteran’s statements and assertions that low back disability are related to his military service. Certainly, he is competent to describe experiencing symptoms. To the extent that the Veteran contends that a medical relationship exists between his claimed current disability and service the Board acknowledges that the Veteran is competent to testify as to his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Nevertheless, a lay person, the Veteran does not have the training or expertise to render a competent opinion which is more probative than the VA examiner’s opinion on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Here, the VA examiner considered the Veteran’s statements and reports of symptoms. The examiner still found that it was unlikely that his reported in-service injuries were related to any current disability. The Board finds that the Veteran’s opinion is outweighed by the competent opinion of the VA examiner. See id. ; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). The Board notes that review of the claims record show inconsistency in the Veteran’s reported history and symptoms of his claimed disability. Such inconsistencies include the Veteran reporting at the July 2016 VA examination that he suffered a fall to his back conflicting with his September 2018 testimony that his back pain resulted from carrying heavy equipment during service and the September 2019 VA examiner noting the Veteran’s inconsistent report of symptoms and history for his claimed disability. Given the inconsistencies of the statements made by the Veteran compared to the medical findings in the treatment record, the Board affords the Veteran’s statements less probative weight and outweighed by VA examinations of record performed by professionals. Based on the above, the Board finds that the competent evidence on record is against a finding of service connection for the Veteran’s low back disability. The Board first notes that service connection may be granted on a presumptive basis for certain chronic diseases, including arthritis, if such disease is shown to be manifest to a degree of 10 percent or more within one year following the Veteran’s separation from active military service. See 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. In this instance however, service connection for a back condition on a presumptive basis is not warranted as the record does not show evidence of degenerative disc disease of the lumbar spine arose during the Veteran’s period of active military service, or within one year of separation from active duty service. Notably, review of the medical treatment record shows the first medical evidence documenting any back related complaints was in 2005, many years after his separation from active duty. As such, the available medical evidence does not support or show that the Veteran’s back condition was present to a compensable degree within a year of the Veteran’s separation from service. Accordingly, service connection for a back disability on a presumptive basis is not warranted as a chronic disease did not manifest to a degree of 10 percent or more within one year following the Veteran’s separation from active military service. Review of the Veteran’s active duty STR show no complaints, treatment or diagnosis of a low back disability. Review of the medical treatment record shows the earliest competent documentation relating to the Veteran’s low back disability was in 2005, many years after separation from active duty service. Significantly, the only medical opinion addressing the etiology of the claimed low back disability is the September 2019 examiner’s opinion. The September 2019 VA examiner considered the Veteran’s report of symptoms but provided analysis of the case record to support their opinion that the Veteran’s current low back disability was less likely than not incurred in or caused by the Veteran’s active duty service. The Board thus finds that the weight of the competent and probative evidence is against a finding of service connection for the Veteran’s low back disability. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Diabetes mellitus The Veteran contends that his diabetes mellitus is related to his active duty service. Review of the Veteran’s medical treatment record shows the Veteran receiving treatment and diagnosis for diabetes mellitus. A July 2020 VA examiner diagnosed the Veteran with diabetes mellitus. As such, the Board finds the Veteran with a current disability. Review of the Veteran’s service treatment records (STRs) shows in a January 1990 psychiatry referral, the Veteran was seen for an assessment for fitness of duty following two episodes of bedwetting. The treating provider noted that the episodes could either be a urinary tract infection which the Veteran was currently undergoing treatment for; or an increase in stress as the Veteran reported that he was currently learning to swim in the service. The treating provider found the problem to be acute in nature and anticipated it would “quickly disappear.” in June 1992 the Veteran reported symptoms of urinary frequency and urgency. The Veteran reported that his father and both grandmothers had diabetes. The treating physician gave an assessment of “urinary tract infection vs. diabetes mellitus” but did not clarify what diagnosis the Veteran had; followup laboratory testing was ordered. In a followup July 1992 visit, the provider assessed the Veteran with polyuria with unknown etiology. In an August 1992 followup, the Veteran reported relief of prior symptoms but now reported nocturia and bed wetting. The treating provider assed the Veteran with bladder control of unknown etiology. A test for urinary retention found no abnormalities. In a later August 1992 visit the Veteran was seen for urinary frequency. The treating provided that review of lab reports was negative and assessed the Veteran with “urinary symptoms of undetermined etiology.” In a January 1993 assessment for fatigue syndrome, the Veteran’s glucose level was documented at 90. No diagnosis for diabetes mellitus was made at this visit. At the Veteran’s March 1993 separation examination, no complaints or symptoms relating to urinary issues or diabetes mellitus were found or reported. The treating physician did not find or diagnose the Veteran with diabetes mellitus. Review of the Veteran’s medical treatment record shows in March 2013 the Veteran reported that he had been diabetic since 2011. Followup visits in May 2013 show reports and treatment for uncontrolled diabetes mellitus. At the Veteran’s September 2018 hearing, the Veteran testified his diabetes mellitus was related to his service because “sometimes I would get kind of, you know, dizzy”, but stated that he never went to sick call. The Veteran further stated that he did not want to be viewed as “weak…[a] kind of malingerer and a liar”. The Veteran was afforded a July 2020 VA examination. The examiner diagnosed the Veteran with diabetes mellitus with an onset in 2007. The examiner noted that review of the Veteran’s available record and findings were considered while completing the examination. The Veteran did not report any medical history regarding his diabetes mellitus at this examination. The examiner found it was less likely than not that the Veteran’s diabetes mellitus was related to his active duty service. The examiner noted the Veteran’s STR showed a blood sugar level of 90 in January 1993 and reported symptoms of fatigue and urinary frequency; however, the examiner noted that no diagnosis of diabetes mellitus was rendered. The examiner also noted that the Veteran at his separation examination in March 1993 did not have diabetes mellitus listed as an active medical condition and did not submit any treatment records within a year of his discharge to show a diagnosis of diabetes mellitus. The examiner found that the Veteran’s diagnosis of diabetes mellitus had its onset in 2007 which would be many years after the Veteran’s separation from service. After review of the evidence, the Board finds the preponderance of the evidence is against a finding that the Veteran’s diabetes mellitus is related to his active duty service. Review of the Veteran’s STRs do not show any clear diagnosis for diabetes mellitus. Review of the Veteran’s medical treatment record shows the earliest competent medical documentation relating to the Veteran’s diabetes mellitus was in 2013, many years after the Veteran’s separation from service. The July 2020 VA examiner found the Veteran’s diabetes mellitus arose in 2007 but that would still be years after the Veteran’s separation from service. The objective evidence does not suggest the onset of the Veteran’s diabetes mellitus occurred during service or the symptoms associated with his disabilities began more than one year after separation from service. The Veteran has not submitted any medical opinions to support his claim that his diabetes mellitus is related to his active duty service; The only evidence in support of such a link is the Veteran’s lay assertions. The Board acknowledges the Veteran’s assertions that his diabetes mellitus was related to his military service. Certainly, he is competent to describe experiencing symptoms in service and recurring thereafter. Nevertheless, a lay person, the Veteran does not have the training or expertise to render a competent opinion which is more probative than the VA examiner’s opinion on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Here, the July 2020 VA examiner reviewed the Veteran’s STRs and his report of symptomatology thereafter and provided reasoned analysis of the case to support their opinion that the Veteran’s current diabetes mellitus was not incurred in or caused by the Veteran’s active duty service. The Board finds that the Veteran’s opinion is outweighed by the competent opinions of the VA examiner. See id. ; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). As the July 2020 VA examiner provided a detailed review and examination of the appellant’s claims file, made repeated references to pertinent past records to include the appellant’s STRs, and statements consistent with the evidence of record, the Board finds that the July 2020 VA examination report and medical records documenting the nature and extent of the appellant’s diabetes mellitus, to be the most probative evidence of record. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As there have been no other probative opinions submitted in support of the Veteran’s claim, the July 2020 opinion is the only probative opinion of record. As such, the Board thus finds that the weight of the competent and probative evidence is against a finding of service connection for the Veteran’s diabetes mellitus. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Cataracts and Diabetic Neuropathy of the bilateral lower extremities The Veteran asserts that his cataracts and diabetic neuropathy of the bilateral lower extremities are related to his active duty service. The Board notes in the Veteran’s December 2015 claim, the Veteran claimed cataracts as secondary to service-connected disabilities but did not specify a service-connected disability. The Veteran is currently service connected for fatigue syndrome; PTSD; left ankle strain with achilles tendonitis; recurrent sinusitis; tinnitus; and bilateral hearing loss. As addressed above, the Board is also granting a separate rating for rhinitis. Regarding cataracts, review of the medical treatment record shows the Veteran was diagnosed with bilateral cataracts in September 2015. In a June 2016 VA examination, the examiner noted the Veteran was diagnosed with cataracts in 2015 and received surgery in January 2016 to remove them; the Veteran was diagnosed with pseudophakia with no diagnosis for cataracts. Regarding diabetic neuropathy of the bilateral lower extremities, a June 2016 VA examination diagnosed the Veteran with diabetic neuropathy of the bilateral lower extremities. Review of the medical treatment record shows complaints and treatments for numbness and tingling in the lower extremities. As such, the Board finds the Veteran with current or diagnosed disabilities for cataracts and diabetic neuropathy of the bilateral lower extremities during the appeal period. Review of the Veteran’s STRs do not show any complaints, treatments or diagnoses for cataracts or diabetic neuropathy of the bilateral lower extremities. Review of the medical treatment record shows in April 2015 visit for low back pain the Veteran was also seen for evaluation for lower extremity numbness; tingling; and pain for the past 3 months. In May 2015 the Veteran was given a steroid injection for treatment for back pain. In July 2015 the Veteran was seen for a reported mild form of neuropathy and cold sensation in his feet for the past several months. Physical examination found a severe bunion deformity in both feet as well as mild degenerative changes in the great toe joints upon x-ray. The Veteran was given a diagnosis for hallux valgus. In September 2015 the Veteran was assessed with cataracts. In a December 2015 statement from the Veteran’s wife, she stated the Veteran suffered from leg pain. The Veteran was afforded a June 2016 VA examination. The examiner diagnosed the Veteran with pseudophakia of the eyes and bilateral diabetic neuropathy of the lower extremities. In the VA examination for his eyes, the Veteran stated that he was involved in a “situation in war where oil got into left eye more than right…just washed out and didn’t go to sick call.” The VA examiner remarked that the Veteran’s cataracts were most likely related to his diabetes and/or the steroid injection he received in May 2015; the examiner noted that diabetes and steroids were known to be the most common cause of cataracts. The Board notes that no opinion was given regarding the etiology of his bilateral diabetic neuropathy of the lower extremities in relation to the Veteran’s service; and no opinion was given regarding whether the Veteran’s cataracts were caused or aggravated by his service-connected disabilities. At the Veteran’s September 2018 hearing regarding his cataracts, the Veteran testified that he had no problems with cataracts before service and was “shocked” that he would develop cataracts at such a young age. Regarding his bilateral neuropathy of the lower extremities, the Veteran testified that he had a “couple episodes where I was having problems with my diabetes…I didn’t know it was diabetes, but I was experiencing the same [symptoms].” The Veteran would describe his current symptoms to include constant shooting pain. After review of the evidence of record, the Board finds the greater weight of evidence is against a finding of direct service connection for the Veteran’s claimed diabetic neuropathy of the bilateral lower extremities and for secondary service connection for the Veteran’s claimed cataracts. Review of the Veteran’s STRs show no complaints, treatments or diagnoses for cataracts or diabetic neuropathy of the lower extremities. The earliest medical documentation relating to the Veteran’s claimed condition was in September 2015 for cataracts and April 2015 for his neuropathy of the lower extremities, years after the Veteran’s separation from service. The Veteran has not submitted any other statements, testimony or opinions that show or claim that his diabetic neuropathy of the lower extremities is related to his military service. The Veteran has not provided any statements, testimony or opinions that show a specific service-connected disability which caused or aggravated his cataracts. The Board notes that the Veteran at his June 2016 VA examination stated that he suffered an oil splash into his eyes without going to sick call. However, the Veteran at his September 2018 hearing testified that he did not have an issue with eyes prior to entering the military, did not mention this incident, and otherwise only express his surprise that he had cataracts. The Veteran did not discuss any secondary service-connection theories or specify any service-connected disability that may have caused or aggravated his cataracts nor discuss any direct service connection theory. As addressed above, such inconsistencies undercut the credibility and probative weight given to the Veteran’s submitted statements and testimony. As such, the Board finds the Veteran’s statements to be outweighed by VA examinations of record performed by professionals. Furthermore, the June 2016 VA examiner found the Veteran’s cataracts were most likely due to his diabetes or the May 2015 steroid injection for his low back pain; both of which the Board has addressed above as not service connected. The Board notes that no opinion was obtained for his claimed diabetic neuropathy of the lower extremities or for secondary service connection between his cataracts and his service-connected disabilities; however, the Board finds that a duty to assist error has not been made by the AOJ, as neither an examination nor an opinion is warranted. See McClendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159 (c)(4). Although McClendon sets a low bar, that bar has not been met here as there is no indication of a link between the Veteran’s bilateral diabetic neuropathy of the lower extremities and his active service, or a link between the Veteran’s cataracts and a service-connected disability. The only evidence of a possible connection between the Veteran’s disability and his service or service-connected disabilities are the Veteran’s submitted statements and testimony. However, the Veteran at his September 2018 hearing did not testify to any specific incident or detail to show that his bilateral diabetic neuropathy of the lower extremities was related to his service or a service-connected disability caused or aggravated his cataracts. Such generalized and conclusory statements are not sufficient to trigger VA’s obligation to obtain an examination or opinion. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) (holding that conclusory lay assertion of nexus is insufficient to entitle claimant to provision of VA medical examination). The Board thus finds that the weight of the competent and probative evidence is against a finding of direct service connection for the Veteran’s diabetic neuropathy of the lower extremities or for secondary service connection for the Veteran’s cataracts. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Obstructive sleep apnea (OSA) The Veteran contends his obstructive sleep apnea (OSA) is related to his active duty service. Review of the medical treatment record shows a June 2013 sleep study confirming a diagnosis of OSA. This diagnosis was also referenced by the June 2016 VA examiner in diagnosing OSA. As such, the Board finds the Veteran with a current disability. Review of the Veteran’s STRs do not show complaints, treatments or diagnoses for OSA. In a September 2010 VA examination for CFS, the Veteran reported that his wife has told him that he snores in his sleep. The treating examiner noted the Veteran with a positive history of sleep apnea based upon the reported symptoms of snoring, but no sleep study was made to confirm this finding. In an October 2012 test for testosterone levels, the treating provider noted the Veteran reported frequent fatigue; the provider recommended the Veteran undergo depression screening and OSA testing. In a December 2012 mental health visit, the Veteran was noted to be “unsure why he’s here…schedule a sleep study.” The Veteran’s wife reported observing the Veteran snoring with apneic episodes or instances where he stops breathing; the Veteran reported issues where he is sleepy during the day. In a later December 2012 sleep medicine record, the Veteran reported fatigue during the day, difficulty falling and maintaining sleep, he grits his teeth, snores, and stops breathing in his sleep; the treating provider recommended the sleep study proceed. The provider gave an assessment for sleep disturbance, remarking this was “most likely due to sleep deprivation symptomatic of multiple other sleep problems” but could not rule out other disorders such as hypersomia or narcolepsy. A June 2013 sleep study found the Veteran with mild obstructive sleep apnea and dysfunction of sleep cycle with multiple arousals from sleep. The Veteran was afforded a June 2016 VA examination. The examiner diagnosed the Veteran with OSA and noted the June 2013 sleep study. The Veteran did not provide any statements regarding his OSA in relation to his active duty study. The examiner found the Veteran’s OSA as a diagnosable chronic multi-symptom illness with partially explained etiology; the examiner found it not likely the Veteran’s OSA represented a disability pattern or diagnosed disease related to a specific exposure event during the Veteran’s service in Southwest Asia. At the Veteran’s September 2018 hearing, the Veteran testified that during his service his bunkmates noticed the Veteran snoring really bad and waking up while sleeping. The Veteran stated that the symptoms he had now were the same symptoms he had in service. In an October 2018 buddy statement, the Veteran’s fellow service member stated that they noticed changes in the Veteran’s sleeping behavior and sleep patterns to include observing the Veteran grinding his teeth, his breath stopping, waking up coughing or gasping for air, and headaches. A September 2019 addendum VA medical opinion was obtained. The VA examiner found after review of the Veteran’s claims record to include his testimony that the Veteran’s claimed OSA was less likely than not incurred in or caused by the Veteran’s claimed in-service injury, event or illness. The examiner first stated that medical literature documents that “snoring and daytime sleepiness are common but nonspecific manifestations of OSA.” The examiner next found that medical literature also documented that “well-defined risk factors for OSA include older age, male gender, obesity, craniofacial abnormalities, and upper airway soft tissue abnormalities.” The examiner found that the June 2013 sleep study documented the Veteran with a body mass index (BMI) of 31.6 along with a diagnosis of mild obstructive sleep apnea. The examiner stated that “any sleep apnea that had been present and untreated for 20 years would have more likely resulted in greater severity.” The examiner noted the Veteran in January 2019 had a BMI of 36.75 indicating obesity, “a well-defined risk factor for the development of sleep apnea.” The examiner concluded that any increase in severity was more likely a result of increasing age and weight. After review of the evidence of record, the Board finds the greater weight of evidence is against a finding of direct service connection for the Veteran’s claimed diabetic neuropathy of the bilateral lower extremities and for secondary service connection for the Veteran’s claimed cataracts. Review of the Veteran’s STRs show no complaints, treatments or diagnoses for OSA. The earliest medical documentation relating to the Veteran’s claimed condition was in June 2013, years after the Veteran’s separation from service. The Board acknowledges the Veteran’s statements and assertions that his OSA are related to his military service. Certainly, he is competent to describe experiencing symptoms. To the extent that the Veteran contends that a medical relationship exists between his claimed current disability and service the Board acknowledges that the Veteran is competent to testify as to his observations. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Furthermore, lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) Nevertheless, a lay person, the Veteran does not have the training or expertise to render a competent opinion which is more probative than the VA examiner’s opinion on this issue, as this is a medical determination that is complex. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007); Layno v. Brown, 6 Vet. App. 465, 469-71 (1994)). Here, the VA examiner considered the Veteran’s statements and reports of symptoms. The examiner still found that it was unlikely that his reported in-service injuries were related to any current disability. The Board finds that the Veteran’s opinion is outweighed by the competent opinion of the VA examiner. See id. ; see also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Significantly, the only medical opinion addressing the etiology of the OSA is the September 2019 examiner’s opinion. The September 2019 VA examiner considered the Veteran’s report of symptoms but provided analysis of the case record to support their opinion that the Veteran’s OSA was less likely than not incurred in or caused by the Veteran’s active duty service. The Veteran has not submitted any other medical opinions that show or claim that OSA is related to his military service. The Board thus finds that the weight of the competent and probative evidence is against a finding of service connection for the Veteran’s OSA. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). REASONS FOR REMAND The Board finds that remand is warranted for additional development. Flat feet The Veteran at his September 2018 hearing testified that his flat feet was the result from his duties in service carrying heavy equipment up and down the flight decks during his service. The August 2019 Board decision remanded this issue to afford the Veteran a VA examination to determine the nature and etiology of the Veteran’s claimed flat feet. The Veteran was afforded a July 2020 VA examination, the Veteran reported that he was not aware of any foot problems going into service but stated that his arches collapsed while in service. The examiner opined it was less likely than not that the Veteran’s claimed flat feet were related to his active duty service. The examiner stated that his January 1989 enlistment examination documented bilateral pes planus and symptomatic hallux valgus, but his March 1993 separation examination did not document any foot trouble. The examiner concluded the Veteran’s current diagnoses were a natural progression of a foot condition that existed prior to service and was unrelated to service. However, the examiner does not address or discuss the Veteran’s September 2018 testimony where he stated that his flat feet was caused by carrying heavy equipment during service; such records, statements and testimony may be considered probative in adjudicating the Veteran’s claim. As such, the Board finds the opinion inadequate and clarification warranted to address the Veteran’s testimony. Irritable Bowel Syndrome (IBS) As noted above, an August 2019 Board decision denied entitlement to service connection to IBS as secondary to service-connected disabilities. In the June 2020 JMPR, the Court vacated the Board’s decision on this issue and remanded it back to the Board for readjudication. The Court found in the June 2016 VA examination for the Veteran’s IBS, the VA examiner opined that the Veteran had no current diagnosis of or symptoms consistent with IBS. The examiner also opined that it was not likely the Veteran’s condition represented a disability pattern or diagnosed disease related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The Court found that the VA examiner did not provide any additional rationale or explanation to support these opinions, noting the Veteran at the VA examination reported symptoms of diarrhea two times per day with nausea treated with over the counter medicine but such reports were not addressed specifically by the VA examiner. The Court found the opinion to be conclusory and did not contain sufficient detail for evaluation purposes and found remand was required for an opinion with adequate rationale on the nature and etiology of the Veteran’s IBS. As such, the Board finds remand is warranted to obtain an adequate opinion on the nature and etiology of the Veteran’s IBS in relation to his active duty service. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated and outstanding treatment records. 2. Return the claims file to the VA examiner who conducted the July 2020 examination for flat feet, if available, for clarification and additional opinions. If that examiner is not available, the claims file should be provided to another physician to obtain the requested opinion. After review of the claims file, the examiner is asked to respond to the following: (a.) Address the Veteran’s September 2018 testimony regarding carrying heavy equipment up and down the flight deck during his service to evaluate if the statements and testimony are sufficient for reconsideration of the opinion. (b.) The examiners are advised that the Veteran is competent to report in-service events and treatment, and his symptoms and history, and such reports and assertions must be specifically acknowledged and considered in formulating any opinions. If the examiners reject the Veteran’s reports, the examiners must provide a reason for doing so. (c.) A complete rationale for all opinions expressed should be provided. If any of the above requested opinions cannot be made without resorting to speculation, the examiners must state so and provide a rationale for this conclusion, including an explanation of whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of his irritable bowel syndrome (IBS). The examiner must review the entire claims file, to include a copy of this remand, in conjunction with the examination. In completing this examination, the examiner is asked to respond to the following: (a.) Is it as least as likely as not (a 50 percent or greater probability) the Veteran’s IBS arose in service or is etiologically related to his military service? (b.) Is it as least as likely as not (a 50 percent or greater probability) the Veteran’s IBS is proximately due to his service-connected disabilities? (c.) Is it as least as likely as not (a 50 percent or greater probability) the Veteran’s IBS has been aggravated (worsened beyond natural progression) by his service-connected disabilities? (d.) The examiner is to address the June 2016 VA examination findings, and the January 2005 medical record documenting the Veteran’s complaints of bilateral flank pain, heartburn, pain with eating, flatulence, and diarrhea. (e.) The examiner is also advised that the Veteran is competent to report in-service events and treatment, and his symptoms and history, and such reports and assertions must be specifically acknowledged and considered in formulating any opinions. If the examiner rejects the Veteran’s reports, the examiner must provide a reason for doing so. (f.) A complete rationale for all opinions expressed should be provided. If any of the above requested opinions cannot be made without resorting to speculation, the examiners must state so and provide a rationale for this conclusion, including an explanation of whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion. (g.) If any of the above requested opinions cannot be made without resorting to speculation, the examiner must state so and provide a rationale for this conclusion, including an explanation of whether there is any potentially available information that, if obtained, would allow for a non-speculative opinion. 4. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review, if in order. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Yang, Attorney-Advisor 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.