Citation Nr: 21014701 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 13-01 191 DATE: March 15, 2021 ORDER 1. Entitlement to a rating in excess of 10 percent prior to July 14, 2011 for degenerative disc disease of the lumbar spine (lumbar spine disability) is denied. 2. Entitlement to an initial disability in excess of 10 percent for Crohn's disease with gastroesophageal reflux disease (GERD) is denied. 3. Entitlement to service connection for a left foot disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability, is denied. 4. Entitlement to service connection for a right foot disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability, is denied. 5. Entitlement to service connection for a left hand disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability, is denied. 6. Entitlement to service connection for a right hand disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability, is denied. 7. Entitlement to service connection for a cervical spine disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability, is denied. 8. Entitlement to service connection for a left shoulder disability, to include as secondary to the lumbar spine disability, is denied. 9. Entitlement to service connection for a right shoulder disability, to include as secondary to the lumbar spine disability, is denied. 10. Entitlement to service connection for a right knee disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability, is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the lumbar spine disability manifested with forward flexion greater than 30 degrees but not greater than 60 degrees; combined range of motion of the thoracolumbar spine not greater than 120 degrees; muscle spasms or guarding severe enough to result in abnormal gait or abnormal spinal contour; or incapacitating episodes. 2. The preponderance of the evidence is against finding that the Crohn’s disease with GERD is productive of moderately severe impairment due to frequent exacerbations; there is no malnutrition, anemia, or general debility; severe diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress; or persistently recurrent epigastric distress with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. 3. The preponderance of the evidence is against finding that the left foot disability had an onset in service, manifested to a compensable degree within one year of service discharge, and is not otherwise related to service or caused or aggravated by the service-connected lumbar spine disability. 4. The preponderance of the evidence is against finding that the right foot disability had an onset in service, manifested to a compensable degree within one year of service discharge, and is not otherwise related to service or caused or aggravated by the service-connected lumbar spine disability. 5. The preponderance of the evidence is against finding that the left hand disability had an onset in service, manifested to a compensable degree within one year of service discharge, and is not otherwise related to service or caused or aggravated by the service-connected lumbar spine disability. 6. The preponderance of the evidence is against finding that the right hand disability had an onset in service, manifested to a compensable degree within one year of service discharge, and is not otherwise related to service or caused or aggravated by the service-connected lumbar spine disability. 7. The preponderance of the evidence is against finding that the cervical spine disability had an onset in service, manifested to a compensable degree within one year of service discharge, and is not otherwise related to service or caused or aggravated by the service-connected lumbar spine disability. 8. The preponderance of the evidence is against finding that the left shoulder disability is caused or aggravated by the service-connected lumbar spine disability or is otherwise related to an in-service injury or disease. 9. The preponderance of the evidence is against finding that the right shoulder disability is caused or aggravated by the service-connected lumbar spine disability or is otherwise related to an in-service injury or disease. 10. The preponderance of the evidence is against finding that the right knee disability had an onset in service, manifested to a compensable degree within one year of service discharge, and is not otherwise related to service or caused or aggravated by the service-connected lumbar spine disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent prior to July 14, 2011 for degenerative disc disease of the lumbar spine (lumbar spine disability) have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5234-5243 (2020). 2. The criteria for entitlement to an initial disability rating in excess of 10 percent for Crohn's disease with GERD have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.7, 4.21, Diagnostic Codes, 7319, 7323, 7346 (2020). 3. The criteria for entitlement to service connection for a left foot disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability, 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, 3.310 (2020). 4. The criteria for entitlement to service connection for a right foot disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability, 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, 3.310 (2020). 5. The criteria for entitlement to service connection for a left hand disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability, 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, 3.310 (2020). 6. The criteria for entitlement to service connection for a right hand disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability, 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, 3.310 (2020). 7. The criteria for entitlement to service connection for a cervical spine disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability, 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, 3.310 (2020). 8. The criteria for entitlement to service connection for a left shoulder disability, to include as secondary to the lumbar spine disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). 9. The criteria for entitlement to service connection for a right shoulder disability, to include as secondary to the lumbar spine disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2020). 10. The criteria for entitlement to service connection for a right knee disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability, 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, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1962 to December 1973. The Board remanded these matters in January 2018 and December 2019 for additional development. In consideration of the appeal, the Board is satisfied there was substantial compliance with the remand directives and will proceed with review. Stegall v. West, 11 Vet. App. 268 (1998). Additional VA treatment record have been associated with the claims file since the most recent supplemental statement of the case (SSOC) was issued and the claims being transferred to the Board. However, the Board finds these treatment records are duplicative of records that were previously associated with the claims file. For example, at the time of the December 2020 SSOC, of record were VA treatment records from August 2000 to December 2020 from VA facilities in Tennessee, Florida, and Washington state. The additional VA treatment records fall within those same facilities with the same dates. Therefore, the Board may proceed with review without seeking a waiver. Increased Rating Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 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 the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of the disability will be resolved in the veteran’s favor. 38 C.F.R. § 4.3. The U.S. Court of Appeals for Veteran’s Claims (Court) has held that, in determining the present level of a disability for an increased evaluation claim, the Board must consider the application of staged ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In other words, where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings would be necessary. 1. Entitlement to a rating in excess of 10 percent prior to July 14, 2011 for the lumbar spine disability From the date of claim to July 14, 2011, the Veteran was in receipt of a 10 percent rating based on painful or limited motion of his lumbar spine. The Veteran was provided a VA examination in December 2009. The examiner noted that the Veteran had a laminectomy in 2008, and the Veteran reported constant pain in his low back, which he described as sharp, severe, and constant. The Veteran denied flare-ups and incapacitating episodes, but he reported that he used a cane and was unable to walk more than a few yards. The Veteran also reported that he had pain with prolonged walking, standing, and sitting, and he reported that pain wakes him up at night. The examiner noted that his posture was normal, though his gait was antalgic, and the examiner documented that there was no evidence of ankylosis, muscle spasms, atrophy, or guarding. Range of motion testing revelated flexion to 70 degrees, extension to 25 degrees, left and right lateral rotation 30 degrees, and left and right lateral flexion to 30 degrees. The examiner noted that there was pain with motion on both sides, but the Veteran did not exhibit tenderness or weakness. There was also no additional loss of range of motion after repetitive use. Private treatment records from January 2010 documented that range of motion in the Veteran’s lumbar spine was normal. VA treatment records from February 2010 documented that the Veteran was reporting increased pain that was aggravated by walking, and he had another laminectomy in February 2010, per his private treatment records. VA treatment records from March 2010, just six weeks after his laminectomy, document that the Veteran no longer had pain in his lumbar spine. Private records from April 2010 note that just a few months after his surgery, his range of motion in the spine was normal, muscle strength and tone in the spine was normal, the incision was healing well, and his gait was normal. VA records from April 2010 also document that the Veteran was healing well from his surgery, noting that he was making excellent physical progress. June 2010 VA treatment records document that the Veteran was extremely pleased with the outcomes from his laminectomy, and February 2011 private records document that the pre-operative lumbar spine symptoms remain resolved. Service-connected spine disabilities are rated under Diagnostic Code 5237, which pertains to lumbosacral or cervical strain. Lumbosacral strain is to be evaluated under the General Rating Formula for rating diseases and injuries of the spine. 38 C.F.R. § 4.71a, Diagnostic Code 5237. Intervertebral disc syndrome (IVDS) will be evaluated under the general formula for rating diseases and injuries of the spine or under the formula for rating IVDS based on incapacitating episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Under the General Rating Formula for Diseases and Injuries of the Spine, with or without symptoms such as pain (whether or not it radiates), stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply to lumbar spine disabilities. An evaluation of 20 percent is warranted if forward flexion of the thoracolumbar spine is greater than 30 degrees, but not greater than 60 degrees; the combined range of motion of the thoracolumbar spine is not greater than 120 degrees; or if there is muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. 38 C.F.R. § 4.71a, Diagnostic Codes 5235–5243. A 40 percent evaluation is warranted if forward flexion of the thoracolumbar spine is limited to 30 degrees or less or if there is favorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235–5243. A 50 percent evaluation is warranted if there is unfavorable ankylosis of the entire thoracolumbar spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235–5243. A 100 percent evaluation is warranted if there is unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, Diagnostic Codes 5235–5243. Under the Formula for Rating IVDS Based on Incapacitating Episodes, a 20 percent rating is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. For purposes of evaluation under Diagnostic Code 5243, an “incapacitating episode” is a period of acute signs and symptoms due to IVDS that require bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243. Unfavorable ankylosis is a condition in which the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (zero degrees) always represents favorable ankylosis. 38 C.F.R. § 4.71a, n. 5. For VA compensation purposes, normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the thoracolumbar spine is 240 degrees. 38 C.F.R. § 4.71a, General Rating Formula, note 1. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to decreased movement, weakened movement, excess fatigability, incoordination, and pain on movement, swelling, and deformity or atrophy of disuse. Painful motion is considered limited motion at the point that pain actually sets in. See VAOPGCPREC 9–98. As the Veteran is already in receipt of the minimal compensable rating based on pain and limitation of motion, the Board will assess whether a rating in excess of 10 percent is available based on the General Rating Formula for Diseases and Injuries of the Spine. As noted above, a 20 percent rating requires forward flexion of the lumbar spine greater than 30 degrees but not greater than 60 degrees; a combined range of motion of the thoracolumbar spine not greater than 120 degrees; or muscle spasms and guarding severe enough to result in an abnormal gait or abnormal spinal contour. As noted above, prior to his February 2010 laminectomy, the December 2009 VA examiner documented forward flexion of the thoracolumbar spine was only limited to 70 degrees, and the combined range of motion was 215 degrees. After the surgery, treatment records document that range of motion of the lumbar spine was normal. Furthermore, the December 2009 VA examiner did not document guarding or muscle spasms, despite noting an antalgic gait, and after his February 2010 laminectomy, the Veteran’s gait was documented to be normal. Thus, the Board finds that the Veteran does not meet the criteria for a 20 percent rating based on the General Rating Formula for Disease and Injuries of the Spine prior to July 14, 2011. The Board has also considered whether a rating in excess of 10 percent is available under Diagnostic Code 5243 for this period on appeal. However, the Board notes that the preponderance of the probative evidence of record for this period on appeal does not document that the Veteran has not experienced or reported incapacitating episodes related to his lumbar spine disability. Finally, the Board has considered whether a temporary total rating is warranted based on the February 2010 laminectomy. The Board finds a temporary total rating is denied as the evidence is against finding that the surgery caused convalescence, nor did the Veteran have significant post-operative symptoms. Rather, just six weeks after his surgery, the Veteran reported he no longer had pain. Additionally, a March 2010 letter from the private treatment provider noted that the Veteran had resolution of his post-operative symptoms. The December 2020 VA examiner noted that the evidence did not document that the Veteran required convalescence after his February 2010 laminectomy, nor did he have significant post-operative residuals. As the Veteran’s symptoms do not rise to the level prescribed by the rating criteria for a rating in excess of 10 percent for the lumbar spine, entitlement to a rating in excess of 10 percent prior to July 14, 2011 is denied. 2. Entitlement to an initial disability in excess of 10 percent for Crohn's disease with GERD The Crohn’s disease with GERD is currently rated by analogy under Diagnostic Code 7323, which provides ratings for ulcerative colitis. When a disability is not listed in the rating schedule, it may be rated by analogy to a closely related disease or injury in which not only the functions affected, but also the anatomical area and symptomatology are closely analogous. 38 C.F.R. § 4.20. VA treatment records from 2011 generally document that the Veteran was experiencing decreased fatigue, weight loss, bloating, diarrhea, and a decreased appetite related to his GERD and a small hiatal hernia. In January 2012, an assessment of these symptoms was noted to have been consistent with inflammatory bowel disease and Crohn’s disease. In March 2012, the Veteran was admitted to the VA hospital for a flare-up of Crohn’s. He reported problems with nausea, diarrhea, weight loss, a small hiatal hernia, focal active colitis with moderate activity, and abdominal pain that was getting worse. It was noted that the Veteran could only tolerate fluids. The Veteran was provided a VA examination in March 2012. The examiner noted that the Veteran had a longstanding diagnosis of rheumatoid arthritis, and the Veteran reported that in October 2010, he switched medications for his rheumatoid arthritis. By November 2010, the Veteran reported he began experiencing significant gastrointestinal systems and lost approximately 20 pounds. He reported various testing and treatments until he was ultimately diagnosed with an inflammatory bowel disease most consistent with Crohn’s disease. The examiner documented current symptoms included dysphagia, pyrosis, reflux, sleep disturbance, and recurrent nausea and vomiting four or more times per year. The examiner noted that a September 2011 endoscopy showed a small abnormal hernia, and a diagnosis of GERD and Crohn’s disease was reported. April 2012 VA treatment records document that the Veteran was again admitted for a Crohn’s flare-up that was causing acute and worsening abdominal pain and ongoing nausea. At this time, the Veteran did not report vomiting, but he was tolerating liquids and soft foods only. It was also noted that he had persistent and chronic diarrhea and colitis with moderate activity, though the examiner noted that there was little evidence that Crohn’s colitis was an important part of the Veteran’s disease. VA records document that the Veteran had lost approximately 40 pounds over the last year since the onset of the symptomatology associated with his Crohn’s disease and GERD. However, following his April 2012 admission, VA treatment records from the end of that month document that the Crohn’s disease and GERD had stabilized. June 2012 VA treatment records document ongoing symptomatology associated with his Crohn’s disease, including nausea for the last 10 days, but the Veteran reported that he was eating well and had gained weight. VA treatment notes again document that the Crohn’s colitis was not an important part of his disease, and he had no ulcers, edema, erosions, or important mucosal changes. The Veteran was noted to be doing well with his Crohn’s other than mild pain and some loose stools, though the Veteran noted that he no longer had significant diarrhea. August 2012 VA psychiatric notes document that the Veteran was still struggling to manage his diet related to his Crohn’s diagnosis, and he reported that he was unable to eat big meals but rather was eating several small meals. He also reported that his symptoms had improved. September 2012 VA treatment records document that the Veteran no longer had significant diarrhea, though he reported ongoing loose stools. These records also document that the Veteran is no longer having an active Crohn’s flare. By November 2012, VA treatment records document that the stomach is doing “great.” He reported that he is sometimes constipated and sometimes has diarrhea but noted that the symptoms had evened out and his nausea had resolved. The notes document that the Crohn’s disease was stable, and the Veteran was eating better. VA treatment records throughout 2013 and 2014 document that the Veteran occasionally reported intermittent diarrhea, but treatment providers continuously note that the Crohn’s disease is stable. The Veteran denied abdominal pain or significant weight loss. In June 2014, the Veteran reported a worsening of symptoms related to bowel movements and watery stools, but by January 2015, the Veteran was reporting he had not had heartburn for a month, and his bowel symptoms had gotten better, noting that he occasionally had a bowel movement within 30 minutes of eating. In February 2015, the Veteran reported increased diarrhea and decreased appetite after altering his medications, but he reported very little overall change from his baseline symptoms. He reported that he has fairly constant diarrhea, but he described this as a bowel movement after eating and denied abdominal pain, nausea, and vomiting. VA treatment records for the remainder of 2015 document that the Veteran has diarrhea on some days but that he had maintained his baseline. He denied cramping, bloating, and a decreased appetite, and his Crohn’s is frequently documented as being well-controlled. January 2016 VA treatment records document that the Veteran’s weight has remained stable, despite occasional periods of diarrhea, but it was noted that the Veteran was doing okay from a gastrointestinal perspective. His bowel habits were reasonably regular, he denied abdominal pain, his weight was steady, and he was eating well. June 2016 VA treatment records documented that his weight had remained stable, and his Crohn’s was well-controlled, despite frequent episodes of diarrhea and anorexia. The Veteran was provided another VA examination in February 2017. This examiner noted that the GERD and Crohn’s disease had improved with medication. The only symptomatology documented related to the GERD was reflux and regurgitation, though they were noted to be controlled with medication. The examiner checked that the Veteran did not have esophageal stricture, spasm, or acquired diverticulum, and the examiner checked that there was no other functional impact or pertinent findings related to GERD. The Veteran reports that his Crohn’s symptoms had been largely the same following the initial flare-up and onset. He reported bowel movements right after eating that he described as loose stools as well as random diarrhea with no pattern, but he denied weight loss. In August 2017 VA treatment records, the Veteran reported that he had a Crohn’s flare that caused severe abdominal pain, bloating, and vomiting, noting that he went to the emergency room. His medication was changed, but he reported that he continued to have nausea and bloating. However, VA treatment records from March 2018 document that the symptoms had returned to his baseline, noting only frequent loose bowel movements and urgency after eating. May 2019 VA treatment records document that the Crohn’s disease caused occasional bouts of diarrhea, nausea, and vomiting, noting that the last flare-up of these symptoms was in December 2018, and he noted that this was his only Crohn’s flare since 2017. The Veteran reported that his baseline is “mushy bowel movements” three to four times per day following meals, and he generally does not experience abdominal pain or upper gastrointestinal symptoms. Throughout 2020, VA treatment records document no gastrointestinal complaints and only occasional diarrhea, and the Veteran continuously noted that his Crohn’s disease was stable and denied experiencing nausea, vomiting, diarrhea, and constipation. A final VA examination was provided in December 2020. The examiner documented that the GERD symptoms had remained largely the same since the onset of GERD in September 2011. The examiner documented that the Veteran experienced substernal pain due to his GERD, which was noted to be more likely than not due to an undiagnosed hiatal hernia. The examiner noted that this hiatal hernia was ultimately diagnosed after the Veteran was diagnosed with GERD. The examiner noted that the Veteran did not have sleep disturbances, material weight loss, nausea, vomiting, hematemesis, melena with moderate anemia, esophageal stricture, spasms of the esophagus, or acquired diverticulum of the esophagus. The examiner noted that there were not any other pertinent findings. As for the 2012 diagnosis of Crohn’s disease, the examiner documented that the symptoms have stayed largely the same since his diagnosis. The Veteran reported occasional diarrhea, but the examiner did not check the boxes to indicate that the Veteran had alternating diarrhea and constipation, abdominal distension, anemia, nausea, or vomiting. The Veteran had episodes of bowel disturbance and bowel distress, but they were described as occasional, rather than frequent or more or less constant. The examiner documented that there was no evidence of weight loss, malnutrition, serious complications, tumors, neoplasms, or other general health effects. The examiner documented an ongoing diagnosis of a hiatal hernia. As the Veteran is currently in receipt of a 10 percent rating under Diagnostic Code 7323, the Board will first assess whether a higher rating is available under this diagnostic code. Diagnostic Code 7323 provides for a 10 percent rating with moderate, infrequent exacerbations. A 30 percent rating is assigned for moderately severe ulcerative colitis, with frequent exacerbations. A 60 percent rating is assigned for severe ulcerative colitis, with numerous attacks a year and malnutrition, the health only fair during remission. A 100 percent rating is assigned for pronounced ulcerative colitis resulting in marked malnutrition, anemia, and general debility, or with serious complication as liver abcess. 38 C.F.R. § 4.114, Diagnostic Code 7323. The Board notes that the VA treatment records document that the Veteran has chronic colitis with moderate activity, consistent with the currently assigned 10 percent disability, though it is frequently noted that the colitis is not an important part of the Crohn’s disease. As the preponderance of the evidence is against finding that the colitis is an important part of the Crohn’s disease, nor is it documented to be moderately severe in nature, the Board finds a rating in excess of 10 percent under Diagnostic Code 7323 is denied. As the Veteran’s symptomatology is frequently reported to involve bowel symptoms rather than colitis, the Board has also considered whether the Crohn’s disease would be more properly rated by analogy under Diagnostic Code 7319, which provides ratings for irritable colon syndrome. Under Diagnostic Code 7319, a noncompensable rating is warranted when the Veteran experiences mild symptoms, such as disturbances of bowel dysfunction with occasional episodes of abdominal distress. Moderate symptoms with frequent episodes of bowel disturbance with abdominal distress warrants a 10 percent rating. Finally, a 30 percent rating is warranted for severe symptoms with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress. 38 C.F.R. § 4.114, Diagnostic Code 7319. As noted above, the Veteran has intermittent bowel and abdominal symptoms during his mild flare-ups of Crohn’s, and during more severe flare-ups, the Veteran had occasional episodes of more frequent diarrhea and more regular loose stools. However, the VA treatment records from 2012 to the present generally note that the Crohn’s disease is stable with only occasional episodes of abdominal distress and episodes of bowel disturbances three to four times a day. The bowel symptoms include mild symptoms of occasional bowel disturbance and abdominal distress. During more severe flare-ups, which the Board notes the records document are relatively infrequent, the symptoms involve three to four episodes of loose stool and occasional diarrhea after eating. The preponderance of the evidence is against a finding that the Veteran has severe symptoms with diarrhea or alternating diarrhea and constipation with more or less constant abdominal distress to warrant a 30 percent rating under Diagnostic Code 7319. The Board acknowledges that the Veteran was admitted to the hospital and went to the emergency room on two occasions related to his Crohn’s symptoms, and on those occasions, he reported more severe symptoms of diarrhea, nausea, and significant abdominal pain. However, the most severe and longer lasting of these incidents took place in the early onset and diagnosis process for the Crohn’s disease in March and April 2012, prior to the stabilization of the condition. The records support that these more severe symptoms lasted for approximately one month. The Board finds that rating the Veteran on the severity of symptoms that had stabilized within a few weeks would not be warranted, as these symptoms are only occasional, which symptoms are contemplated by the 10 percent rating, and these symptoms do not represent the total disability picture or the general symptomatology for the disability. See 38 C.F.R. § 4.1 (noting the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability). The Veteran had another severe flare-up of his Crohn’s disease in August 2017. However, again, this was only one instance of more severe symptoms, which are contemplated by the 10 percent rating, and the total disability picture more closely approximates that his symptoms are stable and mild in nature. The Board finds that the bowel symptoms more closely approximate, at worst, a 10 percent rating over the period on appeal, and thus, a rating in excess of 10 percent is denied. Finally, the Board notes that the Crohn’s manifests with GERD and a hiatal hernia. Thus, the Board will also consider whether the disability would be more properly rated by analogy under Diagnostic Code 7346, which provides ratings for hiatal hernias. Under Diagnostic Code 7346, a 30 percent rating is assigned for persistently recurrent epigastric distress, with dysphagia, pyrosis, and regurgitation, accompanied by substernal or arm or shoulder pain, productive of considerable impairment of health. A 60 percent evaluation is assigned for symptoms of pain, vomiting, material weight loss and hematemesis or melena with moderate anemia; or other symptom combinations productive of severe impairment of health. A minimum 10 percent rating is warranted where the evidence demonstrates the presence of two or more of the symptoms identified in the criteria for the 30 percent rating, but of less severity. 38 C.F.R. § 4.114, Diagnostic Code 7346. The Board finds a thorough review of the claims file does not document that the Crohn’s disease with GERD and a hiatal hernia cause persistently recurrent epigastric distress, dysphagia, pyrosis, or regurgitation to approximate a considerable impairment of health. Again, the Veteran has had a few more severe flare-ups of his symptomatology. However, these flare-ups are infrequent and are not representative of his total disability picture, and, while these flare-ups cause some epigastric distress and abdominal pain, given their infrequency over the approximately eight years of disability, the Board does not find that these episodes of epigastric distress rise to the level of “persistently recurrent.” As the disability picture does not demonstrate the presence of two or more of the symptoms identified in the criteria for a 30 percent rating, a separate, compensable rating is not available under Diagnostic Code 7346, and the preponderance of the evidence is against a rating in excess of 10 percent. Given the above, the Board finds that a rating in excess of 10 percent for Crohn’s disease with GERD is denied. 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). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases 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). 3. – 4. Entitlement to service connection for a bilateral foot disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to a lumbar spine disability In an October 2017 statement, the Veteran reported that he believed that his bilateral foot disability had its onset in service, as he believes that the March 1967 notation in his service treatment records (STRs) that he experienced a loss of weight, weakness, tiredness, and lethargy was symptomatic of the onset of rheumatoid arthritis in service. He also reported to an April 2010 VA examiner and in his June 2012 notice of disagreement that the problems related to his spine and hands in service are evidence of the onset of rheumatoid arthritis in service. The Veteran also asserts that his bilateral foot disability is secondary to his spine disability because he has a diagnosis of arthritis of the spine, so he believes that all of his arthritis is related. 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 foot disability. The reasons follow. As to evidence of a current disability, private treatment records from August 2002 document a diagnosis of osteoarthritis in the bilateral foot. A VA examination from April 2010 added a diagnosis of heel spurs, calcaneal spurs, and bilateral hammertoes. VA treatment records from March 2013 include imaging that notes hallux valgus and bilateral plantar calcaneal. VA treatment records from December 2015 document bilateral bunions. VA treatment records from March 2020 document a diagnosis of pes planus. Therefore, the facts establish that the first element of a service-connection claim is met. As to evidence of a disease or injury in service, the STRs do not show that the Veteran experienced a disease or injury to the bilateral foot during service. For example, examinations conducted in March 1965, November 1970, and November 1973, which was the separation examination, all documented that a clinical examination of the feet and lower extremities were normal. Additionally, the Veteran was given a PULHES score of 1 for “L” at the March 1965 and November 1970 examination, suggesting that his lower extremities were at a high level of fitness. The “PULHES” profile reflects the overall physical and psychiatric condition of an individual on a scale of 1 (high level fitness) to 4 (medical condition or physical defect is below the level of medical fitness required for retention in military service). The “P” stands for “physical capacity or stamina,” the “U” stands for “upper extremities,” the “L” stand for “lower extremities,” the “H” reflects the condition of the “hearing and ears,” the “E” is indicative of the “eyes,” and the “S” stand for “psychiatric condition.” Odiorne v. Principi, 3 Vet. App. 456, 457 (1992). The PULHES section was not completed for the November 1973 separation examination. Additionally, in a June 1972 Report of Medical History the Veteran reported that he was generally in good health. On that Report of Medical History, the Veteran reported a positive history of having or having had swollen or painful joints. However, he specifically denied a history of having or having had foot trouble, which the Board finds is highly probative evidence that the reported history of swollen and painful joints did not relate to his feet. The Veteran also reported a positive history of having had or having now “arthritis, rheumatism, or bursitis.” However, the Veteran also specifically circled the word “bursitis” and did not circle arthritis or rheumatism. The Board finds this to be highly probative evidence that the Veteran had not been told that he had a diagnosis of arthritis or rheumatism, nor did he believe he had either such disability at that time. This Report of Medical History was also, notably, completed after the Veteran reported in March 1967 that he had lost weight and felt weak, tired, and lethargic, which he now reports he believes was the onset of his current disabilities. The Board finds this highly probative that the Veteran did not, at the time, have, or believe that he had, osteoarthritis, rheumatoid arthritis or any other major foot disability, while he was in service. Thus, the preponderance of the evidence is against the second element of a service-connection claim being met. Additionally, as to evidence of a nexus between the various current disabilities and service, the Board also finds that this element of a service-connection claim is not met. Multiple VA examiners have opined that the osteoarthritis, along with the other various diagnoses of the bilateral foot, are not at least as likely as not related to the Veteran’s service. The April 2010 VA examiner opined that the current feet disabilities were more commensurate to his age (citing medical literature that reported that advanced age is one of the strongest risk factors associated with osteoarthritis), and the December 2020 VA examiner opined that the various disabilities of the bilateral foot were not at least as likely as not related to service, explaining that the STRs do not document a significant injury in service, nor do the STRs document a diagnosis of osteoarthritis. Rather, the December 2020 examiner opined that his current disabilities are more likely than not caused by injury or overuse after service or are due to the natural progress of aging. The Board finds that the April 2010 and December 2020 VA medical opinions are highly probative, as the examiners had reviewed the file and provided rationales for the conclusions reached, which relied upon the specific facts of the Veteran’s case and medical principles. The April 2010 examiner also cited to medical literature to support the conclusion. These medical opinions are evidence against a nexus between the current bilateral foot disability and service. The Board acknowledges that the Veteran believes that he has rheumatoid arthritis in his bilateral foot. The February 2017 VA examiner documented a diagnosis of rheumatoid arthritis in the feet. However, the vast majority of the reports in the claims file, which includes multiple VA examinations (August 1980, April 2010, and December 2020) and extensive private and VA treatment records do not document that the Veteran has a diagnosis of rheumatoid arthritis in his bilateral foot. Furthermore, the December 2020 VA examiner specifically documented that there was no evidence that the Veteran has rheumatoid arthritis affecting his feet. While the Veteran is competent to report symptoms that he has experienced in service and since service, he is not competent to diagnose rheumatoid arthritis in his bilateral foot, as medical expertise is required. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Furthermore, the Board finds that even if the Veteran has a diagnosis of rheumatoid arthritis of the bilateral foot, the preponderance of the evidence is against finding that the diagnosis had an onset in service or is at least as likely as not related to the Veteran’s service. The February 2017 VA examiner, the only examiner to document rheumatoid arthritis in the feet, opined that the rheumatoid arthritis of the bilateral foot did not have an onset in service as the STRs do not document evidence of problems with his feet. Additionally, the May 2019 VA examiner, after acknowledging the Veteran’s reports of weakness, fatigue, and loss of weight in service, opined that the rheumatoid arthritis did not have an onset in service as photos in service from 1966 do not suggest a diagnosis of rheumatoid arthritis. Rather, the May 2019 examiner noted that risk factors include age (middle age usually), genetics, environmental factors such as asbestos and silica, obesity and smoking. The May 2019 examiner noted that the Veteran had a family history of rheumatoid arthritis and the evidence does not suggest exposure to asbestos in service. Again, the Board acknowledges the Veteran’s belief that his reports of weakness and lethargy in service was an initial sign of the onset of rheumatoid arthritis. However, the Veteran is not competent to directly link those symptoms in service to his later diagnosed rheumatoid arthritis 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. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran has also alleged that the bilateral foot disability is secondary to the service-connected lumbar spine disability. However, the Board finds the preponderance of the evidence is against such a finding. The April 2010 VA examiner specifically opined that the foot disabilities are more commensurate with the Veteran’s age and not related to his lumbar spine (citing medical literature that reported that advanced age is one of the strongest risk factors associated with osteoarthritis). The Board finds this opinion to be probative evidence against secondary service connection, as the examiner provided a rationale for the conclusion, and the Veteran has not provided any other evidence or argument to support his contention that his osteoarthritis is related to his spine, other than that he has arthritis in his spine, and thus, all of his arthritis is related. The Board finds this is not an opinion the Veteran is competent to make as it requires medical expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Despite not meeting the requirements for service connection on a direct or secondary basis, the Board notes that osteoarthritis and rheumatoid 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, in this case, the preponderance of the evidence is against finding that the osteoarthritis had an onset within one year of discharge from service or that the symptomatology continued since service. Rather, the preponderance of the evidence supports a finding that the bilateral foot osteoarthritis was diagnosed many years after the Veteran’s discharge from service. The first documentation of osteoarthritis specific to the bilateral foot was documented in August 2002 private treatment records, approximately 29 years after the Veteran’s discharge from active service, and in March 2011, the Veteran reported that he was diagnosed with arthritis 20 years prior to that treatment, which still suggests an onset in 1991 at the earliest, which is still approximately 18 years after discharge from active service. The preponderance of the evidence is also against a finding that the Veteran had continued symptomatology since service as a VA examination, conducted in August 1980, seven years after the Veteran’s discharge from active service, documented that the range of motion in the entirety of the musculoskeletal system, which includes the feet, was grossly normal. The examination did not document any other symptomatology in the feet. Additionally, at an April 2010 VA examination, the Veteran reported an onset of osteoarthritis in 2000, and, at his February 2017 VA examination, the Veteran reported that he did not experience pain in his feet until 2000 when he was diagnosed with arthritis. The Board finds this is highly probative evidence that the onset of symptomatology related to his bilateral foot was not continuous from his discharge from active 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 claim for service connection for a bilateral foot disability is denied. 5. – 6. Entitlement to service connection for a bilateral hand disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to a lumbar spine disability In an October 2017 statement, the Veteran reported that he believed that his bilateral hand disability had its onset in service as he believes that the March 1967 notation in his STRs that he experienced a loss of weight, weakness, tiredness, and lethargy was symptomatic of the onset of rheumatoid arthritis in service. He reported in a May 1990 statement that he was told at separation by a doctor that his hands were in bad shape and that he would have problems with them later, and in an October 2009 statement, the Veteran reported that he had issues with his hands in 1968 and 1969 during his service in Vietnam. On his March 2011 notice of disagreement, the Veteran reported that he noticed bumps and knots forming on his fingers during his service, and he reported to the February 2017 examiner that his symptoms had an onset in the early 1970s. He also reported to the April 2010 VA examiner on his June 2012 notice of disagreement that the problems related to his spine and hands in service are evidence of the onset of rheumatoid arthritis in service. The Veteran also asserts that his bilateral hand disability is secondary to his spine disability because he has a diagnosis of arthritis of the spine, so he believes that all of his arthritis is related. 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 hand disability. The reasons follow. As to evidence of a current disability, VA treatment records from April 1990 note a diagnosis of osteoarthritic changes in both hands, and at his April 2010 VA examination, the examiner diagnosed rheumatoid arthritis in both hands with superimposed degenerative arthritis or osteoarthritis. Therefore, the facts establish that the first element of a service-connection claim is met. As to evidence of a disease or injury in service, the STRs do not show that the Veteran experienced a disease or injury to his hands during service. For example, examinations conducted in March 1965, November 1970, and November 1973, which was the separation examination, all documented that a clinical examination of the upper extremities was normal. Additionally, the Veteran was provided a PULHES score of 1 for “U” at the March 1965 and November 1970 examinations, suggesting that his upper extremities were at a high level of fitness. The PULHES section was not completed for the November 1973 separation examination. Additionally, in a June 1972 Report of Medical History the Veteran reported that he was in generally good health. The Board acknowledges that on that Report of Medical History, the Veteran reported a positive history of having or having had swollen or painful joints. However, he specifically denied having or having a bone, joint, or other deformity, which the Board finds is highly probative evidence weighing against the credibility of the Veteran’s later statements that he had an onset of bumps and knots in his hands during service. The Veteran checked the box noting a positive history of having had or having now “arthritis, rheumatism, or bursitis.” However, the Veteran also specifically circled the word “bursitis” and did not circle arthritis or rheumatism. The Board finds this to be highly probative evidence that the Veteran had not been told that he had a diagnosis of arthritis or rheumatism, nor did he believe he had either such disability at that time. This Report of Medical History was also notably completed after the Veteran reported in March 1967 that he had lost weight and felt weak, tired, and lethargic, which he now reports he believes was the onset of his current disabilities. The Board finds this highly probative that the Veteran did not, at the time, believe that he had osteoarthritis or any other major foot disability, while he was in service and weighs against the credibility of the Veteran’s statements made many years later in which he reports experiencing symptoms related to his current hand disabilities or having been told he would have future disability in his hands while he was in service. Thus, the preponderance of the evidence is against the second element of a service-connection claim being met. The Veteran, since filing his claim, has asserted that he believes that his rheumatoid arthritis had an onset in service and is related to symptomatology that is documented in his STRs, as noted above. However, while the Veteran is competent to report symptoms that he has experienced in service and since service, he is not competent to diagnose rheumatoid arthritis in his bilateral hand, nor is he competent to assess the onset of a such disability as medical expertise is required. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Additionally, as to evidence of a nexus between the osteoarthritis and rheumatoid arthritis and service, the Board also finds that this element of a service-connection claim is not met. The February 2017 VA examiner opined that the rheumatoid arthritis in the bilateral hand was not diagnosed until the early-2000s, and the disability is less likely than not related to service as the evidence does not suggest that his hand disability began in service and rheumatoid arthritis is an autoimmune disability. Additionally, the May 2019 VA examiner, after acknowledging the reports of weakness, fatigue, and loss of weight in service, opined that the rheumatoid arthritis did not have an onset in service, as photos in service from 1966 do not suggest a diagnosis of rheumatoid arthritis. Rather, the May 2019 examiner noted that risk factors include age (middle age usually), genetics, environmental factors such as asbestos and silica, obesity and smoking. The examiner noted the Veteran had a family history of rheumatoid arthritis, and the evidence does not suggest exposure to asbestos in service. Finally, the December 2020 VA examiner, after noting that the osteoarthritis is likely related to his diagnosis of rheumatoid arthritis, opined that neither diagnosis was at least as likely as not related to the Veteran’s service as the STRs were silent for a diagnosis of osteoarthritis or rheumatoid arthritis and that the current disability were more likely than not due to an injury or overuse after service or to the process of aging. The Veteran has also contended that his bilateral hand disability is secondary to the service-connected lumbar spine disability. However, the Board finds the preponderance of the evidence is against such a finding. The April 2010 VA examiner specifically opined that the hand disabilities are not caused by or a result of the lumbar spine disability, as the hands and the lumbar spine are separate conditions, namely, the hand disability and symptomatology is related to his rheumatoid arthritis, and not osteoarthritis. The opinion that the Veteran’s hand symptomatology was less likely than not related to his lumbar spine disability because his hand disability was caused by rheumatoid arthritis, not the superimposed osteoarthritis, was reiterated by the February 2017 VA examiner. The February 2017 examiner also noted that the joint replacements in the fingers in 1991 and associated with the rheumatoid arthritis is also not related to the lumbar spine disability as there is no connection between the spine and the finger joints. The Board finds these opinions to be probative evidence against secondary service connection as the examiners provided rationales for their conclusions, which was based upon a review of the file and medical principles, and the Veteran has not provided any other evidence or argument to support his contention that his osteoarthritis and rheumatoid arthritis of the bilateral hands is related to his spine, other than that he has arthritis in his spine, and thus, all of his arthritis is related. The Board finds this is not an opinion the Veteran is competent to make as it requires medical expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Despite not meeting the requirements for service connection on a direct or secondary basis, the Board notes that osteoarthritis and rheumatoid 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, in this case the preponderance of the evidence is against finding that the osteoarthritis had an onset within one year of discharge from service or that the symptomatology continued since service. Rather, the preponderance of the evidence supports a finding that the bilateral hand osteoarthritis was diagnosed many years after the discharge from service. The first documentation of osteoarthritis specific to the bilateral hands was documented in April 1990 private treatment records, approximately 17 years after the discharge from active service. The Board acknowledges that the August 1980 VA examiner noted that the Veteran had abnormalities in his ring and middle fingers, deformities that are later noted to be potentially associated with the onset of rheumatoid arthritis. However, even if the Veteran had undiagnosed rheumatoid arthritis in his hands at the time of the August 1980 VA examination, this is still suggestive of an onset of a disability approximately seven years after discharge from active service. The preponderance of the evidence is also against a finding that the Veteran had continued symptomatology since service as the August 1980 VA examination, conducted seven years after the Veteran’s discharge from active service, is the earliest documentation of significant symptomatology associated with the Veteran’s bilateral hands that could potentially constitute the onset of rheumatoid arthritis or osteoarthritis other than the lay statements stating these disabilities and symptoms had an onset in service, which, as noted above, are less credible than the contemporaneous STRs or the Veteran is not competent to provide the opinion. 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 hand disability is denied. 7. Entitlement to service connection for a cervical spine disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability The Veteran reported in a March 2011 notice of disagreement that he believes repairing aircraft in service was the cause of his current cervical spine disability. 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 cervical spine disability. The reasons follow. As to evidence of a current disability, private treatment records from June 1987 document that an x-ray showed mild degenerative changes in the cervical spine, and private treatment records from August 2002 document a diagnosis of osteoarthritis of the cervical spine. Private treatment records from February 2017 noted that imaging of the cervical spine showed moderately severe cervical spondylosis with degenerative disc disease and degenerative arthropathy. Therefore, the facts establish that the first element of a service-connection claim is met. As to evidence of a disease or injury in service, the STRs do not show that the Veteran experienced a disease or injury to his cervical spine during service. For example, examinations conducted in March 1965, November 1970, and November 1973, which was the separation examination, all documented that a clinical examination of the spine was normal. Additionally, in a June 1972 Report of Medical History the Veteran reported that he was in generally good health and did not document a history of having or having had any abnormalities related to his cervical spine, despite noting having of having had many other abnormalities such as swollen or painful joints, eye trouble, ear, nose, or throat trouble, sinusitis, hay fever, a head injury, asthma, shortness of breath, cramps in his legs, frequent indigestion, arthritis, rheumatism, or bursitis, painful or “trick” shoulder or elbow, recurrent back pain, and trick or locked knee. The Board finds that this suggests that the Veteran filled out this form with a great attention to detail given the many abnormalities and notations that were made regarding his medical history, and had he been experiencing symptomatology related to his cervical spine or neck at separation or during his service, he likely would have reported it. The Board finds these highly detailed contemporaneous medical records weigh against the credibility of the Veteran’s statements made after filing his claim that he believes his current cervical spine disability was caused by repairing aircraft in service. Thus, the preponderance of the evidence is against the second element of a service-connection claim being met. Additionally, as to evidence of a nexus between the current cervical spine disability and service, the Board also finds that this element of a service-connection claim is not met. The February 2017 VA examiner, after diagnosing the Veteran with degenerative disc disease of the cervical spine and cervical spine spondylosis, opined that the cervical spine disability was not at least as likely as not related to the Veteran’s service as the STRs do not document an onset or symptomatology in service. The December 2020 VA examiner also opined that the osteoarthritis of the cervical spine is also not at least as likely as not related to the Veteran’s service, reiterating that the STRs did not document an onset of a disability or symptomatology in service, and opining that the current diagnosis was more likely than not related to a post-service injury, overuse, or the process of aging. The Board finds that the February 2017 and December 2020 VA medical opinions are highly probative, as the examiners had reviewed the file and provided rationales for the conclusions reached, which relied upon the specific facts of the Veteran’s case and medical principles. These medical opinions are evidence against a nexus between the current cervical spine disability and service. The Veteran also contends that his cervical spine disability is secondary to the service-connected lumbar spine disability. However, the Board finds the preponderance of the evidence is against such a finding. The April 2010 VA examiner specifically opined that the cervical spine disability was not caused by or a result of his lumbar spine disability as the cervical spine disability is separate from the lumbar spine disability and more likely than not commensurate with age. The Board finds this opinion to be probative evidence against secondary service connection as the examiner provided a rationale for the conclusion, and the Veteran has not provided any other evidence or argument to support his contention that his cervical spine disability is related to his lumbar spine, other than that he has arthritis in his spine, and thus, all of his arthritis is related. The Board finds this is not an opinion the Veteran is competent to make as it requires medical expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Despite not meeting the requirements for service connection on a direct basis, the Board notes that osteoarthritis is a chronic disease 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, in this case the preponderance of the evidence is against finding that the osteoarthritis had an onset within one year of discharge from service. Rather, The Veteran was not diagnosed with osteoarthritis of the cervical spine until August 2002, which is approximately 19 years after discharge from service. Additionally, even if the June 1987 private treatment records that document mild degenerative changes of the cervical spine suggest an onset of osteoarthritis, this notation was made approximately 14 years after the Veteran’s discharge from active service. The preponderance of the evidence is also against a finding that the Veteran had continued symptomatology in his cervical spine since service as a VA examination, conducted in August 1980, seven years after the Veteran’s discharge from active service, documented that the range of motion in the entirety of the musculoskeletal system, which includes the cervical spine, was grossly normal. The examination did not document any other symptomatology in the cervical spine. The Board finds this highly probative evidence that the onset of symptomatology related to his cervical spine was not continuous from his discharge from active 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 claim for service connection for a cervical spine disability is denied. 8. – 9. Entitlement to service connection for a bilateral shoulder disability, to include as secondary to a lumbar spine disability In an October 2009 statement, the Veteran reported that he had issues with his shoulders during his service in Vietnam. On his March 2012 notice of disagreement, the Veteran reported that he injured his shoulders while carrying heavy parts in his work as an aircraft technician. 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 shoulder disability. The reasons follow. As to evidence of a current disability, a December 2020 VA examination report shows that the Veteran was diagnosed with a bilateral shoulder strain dating back to approximately 2009. Therefore, the facts establish that the first element of a service-connection claim is met. As to evidence of a disease or injury, the STRs show that the Veteran reported difficulty with a bursitis in his left shoulder in February 1970. The STRs document that the Veteran believed the injury happened two years prior and that he was experiencing pain with movement at that time. However, records following the February 1970 treatment are silent for ongoing treatment for a right shoulder injury during his active service. For example, examinations conducted in November 1970 and November 1973, which was the separation examination, all documented that a clinical examination of the upper extremities was normal. Additionally, the Veteran was provided a PULHES score of 1 for “U” at the November 1970 examination, suggesting that his upper extremities were at a high level of fitness. The PULHES section was not completed for the November 1973 separation examination. Additionally, in a June 1972 Report of Medical History the Veteran reported that he was in generally good health. On that Report of Medical History, the Veteran reported a positive history of having or having had swollen or painful joints and a painful or “trick” shoulder. The Board finds this is likely related to the left shoulder bursitis, reported by the Veteran in February 1970, and, as noted above, seems to have not caused persistent symptomatology. Thus, as to the left shoulder, the facts establish that the second element of a service-connection claim is met. However, as to the right shoulder, the Board finds the preponderance of the evidence is against an in-service disease or injury. As to evidence of a nexus between the current disability and service, the Board finds that this element of a service-connection claim is not met. The December 2020 examiner opined that the current bilateral shoulder strain was not at least as likely as not related to the left shoulder bursitis in service, nor did the in-service bursitis exacerbate his current bilateral shoulder strain. The examiner noted that bursitis is not a significant injury, and it is inflammatory in nature, which is a condition that is self-limiting and resolves over time. The examiner further opined that the current bilateral shoulder strain was more likely than not related to a non-service-related injury. The Board finds this opinion to be highly probative, as the remainder of the evidence supports the December 2020 examiner’s opinion that the left shoulder bursitis in service resolved over time. In two examinations, conducted in November 1970 and November 1973, notably after the February 1970 STRs documenting a left shoulder bursitis, a clinical evaluation of the upper extremities, which would include the shoulders, was normal. Furthermore, in an August 1980 VA examination, the examiner noted that the range of motion in the musculoskeletal system was grossly normal, suggesting that the Veteran did not have an ongoing shoulder symptoms in the seven years following his service. Private records from November 2008 also document normal joint stability and range of motion of the shoulders. It is not until a November 2009 statement that the Veteran reports pain and stiffness in his shoulders, which is over 35 years after his discharge from active service. The Board acknowledges the Veteran’s statement that he believes his current shoulder symptoms are related to his left shoulder bursitis in service. However, the Board finds the opinion of the December 2020 VA examiner to be more probative, as the opinion is provided by a medical professional competent to report such an opinion, and it is supported by the evidence in the claims file, which notes a decades long gap between the in-service injury and the onset of his current symptoms. Additionally, while the Veteran is competent to report symptoms that he has experienced in service and since service, he is not competent to directly link the current bilateral shoulder disability 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. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As to the claim that his bilateral shoulder disability is secondary to his lumbar spine disability, the Board notes that the Veteran has not provided any contentions or evidence to support this conclusion. Rather, the Veteran has only vaguely asserted a belief that the two disabilities are related. This is not sufficient evidence to grant service connection on a secondary basis, nor is it sufficient to warrant further development as the Veteran has provided no evidence of a relationship between a lumbar spine disability and the onset of pain and stiffness in his shoulder in approximately 2009. 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 shoulder disability is denied. 10. Entitlement to service connection for a right knee disability, to include osteoarthritis and rheumatoid arthritis and to include as secondary to the lumbar spine disability The Veteran has not provided specific contentions related to his right knee disability. However, the Board presumes the Veteran’s assertions are comparable to those made for his various other musculoskeletal claims. 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 right knee disability. The reasons follow. As to evidence of a current disability, private and VA treatment records from 1999 document that the Veteran had a tendon repair in his right knee, and records from 2002 to the present document ongoing pain and a small effusion in the right knee. A December 2020 examination report documents a diagnosis of right knee osteoarthritis. Notably, the December 2020 VA examiner specifically documented that the Veteran did not have rheumatoid arthritis in his right knee. Regardless, the facts establish that the first element of a service-connection claim is met. As to evidence of a disease or injury in service, the STRs do not show that the Veteran experienced a disease or injury to the right knee during service. For example, examinations conducted in March 1965, November 1970, and November 1973, which was the separation examination, all documented that a clinical examination of the lower extremities were normal. Additionally, the Veteran was provided a PULHES score of 1 for “L” at the March 1965 and November 1970 examination, suggesting that his lower extremities were at a high level of fitness. The PULHES section was not completed for the November 1973 separation examination. Additionally, in a June 1972 Report of Medical History the Veteran reported that he was in generally good health. On that Report of Medical History, the Veteran reported a positive history of having or having had swollen or painful joints and noted a history of having or having had a “trick” or locked knee. However, the Veteran did not provide any specifics as it relates to an onset of that symptomatology, nor did an examination of the lower extremities on that same date document any clinical abnormalities in the right knee. Additionally, in a subsequent examination, conducted prior to the Veteran’s separation, a clinical examination of the lower extremities continued to be normal. The Board finds these clinical examinations to be highly probative evidence that the Veteran’s reported history of swollen and painful joints and a “trick” or locked knee was not an ongoing injury during the Veteran’s service. The Veteran checked the box noting having had or having now “arthritis, rheumatism, or bursitis.” However, the Veteran also specifically circled the word “bursitis” and did not circle arthritis or rheumatism. The Board finds this to be highly probative evidence that the Veteran had not been told that he had a diagnosis of arthritis or rheumatism, nor did he believe he had either such disability at that time. This Report of Medical History was also notably completed after the Veteran reported in March 1967 that he had lost weight and felt weak, tired, and lethargic, which he now reports he believes was the onset of his current disabilities. The Board finds this highly probative that the Veteran did not, at the time, believe that he had osteoarthritis while he was in service. Thus, the preponderance of the evidence is against the second element of a service-connection claim being met. Evidence if the Board conceded evidence of a disease or injury in service, the Board also finds that the preponderance of the evidence is against a nexus between the current disability and service. The February 2017 VA examiner opined that the current right knee symptoms were more likely than not related to a 1999 trip and fall incident, as the records did not support that the Veteran had significant knee problems prior to that incident and because his symptoms had improved since that date of onset. The December 2020 VA examiner also opined that the current right knee disability, and the new development of osteoarthritis, were not at least as likely as not related to the Veteran’s service as the STRs did not note a diagnosis of osteoarthritis or a significant knee injury. The examiner further noted that there was no injury in service. The Board finds these opinions are highly probative against a nexus between the current disability and his active service, as the examiners had reviewed the record and provided rationales that were based on the facts and medical principles. Additionally, the Board notes that at the February 2017 VA examination when asked about the onset of his current knee symptoms, the Veteran reported an onset in 1999 when he tripped and fell, tearing both tendons and requiring surgery. This onset is more than 25 years after the Veteran’s discharge from active service and was related to an injury entirely separate from the Veteran’s service. Thus, the Veteran’s own contentions support the opinion provided by the February 2017 and December 2020 VA examiners. The Veteran has also contended that his right knee disability is secondary to the service-connected lumbar spine disability. However, the Board finds the preponderance of the evidence is against such a finding. The February 2017 VA examiner specifically opined that the right knee disability is less likely than not related to the lumbar spine disability as the current symptoms are more commensurate with his 1999 trip and fall injury. The examiner further noted that his symptoms at the time of the examination were consistent with recovery from a tendon repair and were not worse than ongoing symptoms would be expected to be following such an injury. The Board finds this opinion to be probative evidence against secondary service connection, as the examiner provided a rationale for the conclusion, and the Veteran has not provided any other evidence or argument to support his contention that his osteoarthritis is related to his lumbar spine, other than that he has arthritis in his spine, and thus, all of his arthritis is related. The Board finds this is not an opinion the Veteran is competent to make as it requires medical expertise. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Despite not meeting the requirements for service connection on a direct or secondary basis, the Board notes that osteoarthritis is a chronic disease 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, in this case the preponderance of the evidence is against finding that the osteoarthritis had an onset within one year of discharge from service or that the symptomatology continued since service. Rather, the preponderance of the evidence supports a finding that the right knee osteoarthritis was diagnosed many years after the Veteran’s discharge from service. The first documentation of osteoarthritis specific to the right knee was documented in the December 2020 VA examination report, which suggests an onset over 40 years after discharge from active service. The preponderance of the evidence is also against a finding that the Veteran had continued symptomatology since service as a VA examination, conducted in August 1980, seven years after the Veteran’s discharge from active service, documented that the range of motion in the entirety of the musculoskeletal system, which includes the right knee, was grossly normal. The examination did not document any other symptomatology in the right knee. Additionally, as noted above, the claims file does not document symptomatology in the right knee until the trip and fall injury in 1999, approximately 26 years after his discharge from active service. The Board finds this to be highly probative evidence that the onset of symptomatology related to his right knee was not continuous from his discharge from active 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 claim for service connection for a right knee disability is denied. 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.