Citation Nr: 21020727 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 18-09 060 DATE: April 8, 2021 ORDER Entitlement to service connection for a bilateral neuropathy of the feet, to include as secondary to a service connected left knee disorder is denied. Entitlement to service connection for tinnitus is denied. Entitlement to an increased evaluation in excess of 10 percent for the residuals of a gunshot wound, damage to Muscle Group XIV, of the left knee is denied. Entitlement to service connection for a respiratory disorder (other than rhinitis and pharyngitis) is denied. Entitlement to service connection for a vascular disorder of the lower extremities, to include as secondary to service connected left knee disorder is denied. FINDINGS OF FACT 1. The evidence does not support a finding that the Veteran’s bilateral neuropathy of the feet is proximately related to his service connected left knee disorder or is otherwise related to or aggravated by an in-service injury or disease. 2. The evidence does not support a finding that the Veteran’s tinnitus began during active service or is otherwise related to or aggravated by an in-service injury or disease. Tinnitus was first shown years after service. 3. The Veteran’s residuals of a gunshot wound to the left knee is manifested by no more than a moderate injury to Muscle Group XIV. 4. The Veteran’s respiratory disorder pre-existed entry into service and unequivocally did not worsen beyond its natural progression during active service. A chronic respiratory disorder, other than that which is service connected, has not been shown related to service. 5. The evidence does not support a finding that the Veteran’s vascular disorder of the lower extremities is proximately related to his service connected left knee disorder or aggravated by an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for bilateral neuropathy of the feet, to include as secondary to service connected left knee disorder are not met. 38 U.S.C. §§ 1101, 1110, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.310. 2. The criteria for service connection for tinnitus are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. 3. The criteria for an increased evaluation in excess of 10 percent for the residuals of a gunshot wound to Muscle Group XIV of the left knee are not met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.73, Diagnostic Code 5314. 4. The criteria for service connection for a respiratory disorder are not met. 38 U.S.C. §§ 1101, 1110, 1111, 1131, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306. 5. The criteria for service connection for a vascular disorder of the lower extremities, to include as secondary to service connected left knee disorder are not met. 38 U.S.C. §§ 1101, 1110, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty for training from November 1960 to May 1961. He also had active service from October 1961 to August 1962. The Veteran testified before the undersigned at a Board hearing in January 2020. A transcript is on file. In July 2020, the Board remanded these issues for additional development. The Board finds that there was substantial compliance with the remand directives on appeal as discussed below. See Stegall v. West, 11 Vet. App. 268, 271 (1998). While the case was undergoing Remand development, service connection was granted for the residuals of a total left knee replacement and rating s were assigned. Service connection was also granted for residual left knee scarring. There has been no disagreement with that action. As such, the remaining matter before the Board as it refers to the left knee concerns the rating for injury to Muscle Group XIV. The Board also notes, in terms of respiratory impairment, that service connection has been granted for chronic rhinitis and pharyngitis, with telangiectasia, post-pharyngeal wall, rated 10 percent disabling. Respiratory impairment at issue herein is taken to be other impairment not involving the service connected pathology. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information lay and medical evidence of record in a case and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. §5107 (2012); 38C.F.R. §3.102 (2020); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, a preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). For Veterans with 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases may be presumed to have been incurred in service if they manifest to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Tinnitus is on the list of diseases presumed to have been incurred in-service and receives a one-year presumption. Service connection may be established for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. The Federal Circuit has distinguished between those cases in which the pre-existing condition is noted upon entry into service, and cases in which the pre-existence of the condition must otherwise be established. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). In a case where there is no pre-existing condition noted upon entry into service, the Veteran is presumed to have entered service in sound condition, and the burden falls to the government to demonstrate by clear and unmistakable evidence that(a) the condition pre-existed service and(b) the pre-existing condition was not aggravated by service. Wagner, 370 F.3d at 1345. “[I]f a preexisting disorder is noted upon entry into service, the Veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder.” Wagner, 370 F.3d at 1096; see also 38 U.S.C. § 1153; 38 C.F.R. § 3.306. A preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service, unless there is a specific finding that such increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. Clear and unmistakable (obvious, manifest, and undebatable) evidence is required to rebut the presumption of aggravation. 38 C.F.R. § 3.306 (b). The evidence must show a lasting worsening of the condition, meaning an increase in severity that existed at the time of separation from service and still exists currently. Hunt v. Derwinski, 1 Vet. App. 292, 296-97 (1991). To be "noted" within the meaning of the presumption of soundness statute, the condition must be recorded in the entrance examination report. 38 C.F.R. § 3.304 (b). History of pre-service existence of a disease does not constitute a notation of such condition. See Crowe v. Brown, 7 Vet. App. 238, 240 (1994). Increased Ratings Disabilities resulting from muscle injuries are classified as slight, moderate, moderately severe, or severe. 38 C.F.R. § 4.56 (d). The United States Court of Appeals for Veterans Claims (Court), citing Robertson v. Brown, 5 Vet. App. 70 (1993), has held that 38 C.F.R. § 4.56 (d) is essentially a totality-of-the-circumstances test and that no single factor is per se controlling. Tropf v. Nicholson, 20 Vet. App. 317 (2006). A “moderate” muscle disability consists of a through and through or deep penetrating wound of short track from a single bullet, small shell or shrapnel fragment, without the explosive effect of a high velocity missile, residuals of debridement, or prolonged infection. In such cases, there will be a service department record or other evidence of in- service treatment for the wound and a record of consistent complaint of one or more of the cardinal signs and symptoms of muscle disability, particularly a lowered threshold of fatigue after average use, affecting the particular functions controlled by the injured muscles. Objective findings typically include entrance and (if present) exit scars, small or linear, indicating a short track of the missile through muscle tissue; some loss of deep fascia or muscle substance or impairment of muscle tonus and loss of power or a lowered threshold of fatigue when compared to the sound side. 38 C.F.R. § 4.56 (d)(2). A “moderately severe” disability of the muscles is shown by a through and through or deep penetrating wound by a small high velocity missile or a large low velocity missile, with debridement, prolonged infection, or sloughing of soft parts, and intermuscular scarring. History and complaints of this injury typically include a record of hospitalization for a prolonged period for treatment of a wound, a record of consistent complaint of cardinal signs and symptoms of muscle disability, and, if present, evidence of an inability to keep up with work requirements. Objective findings of a moderately severe muscle wound are entrance and (if present) exit scars indicating the track of the missile through important muscle groups; indications on palpation of moderate loss of deep fascia, muscle substance, or normal firm resistance of muscles compared with the sound side; and tests of strength and endurance compared with the sound side demonstrating positive evidence of impairment. 38 C.F.R. § 4.56 (d)(3). For VA rating purposes, the cardinal signs and symptoms of a muscle disability are loss of power, weakness, lower threshold of fatigue, fatigue-pain, impairment of coordination, and uncertainty of movement. 38 C.F.R. § 4.56 (c). The Veteran’s left knee gunshot wound residuals are rated at 10 percent disabling under Diagnostic Code 5314. As noted, the Veteran was granted separate evaluations under Diagnostic Code 5055 for a left knee arthroplasty, Diagnostic Code 7802 for left knee associated surgical scar, and Diagnostic Code 5055 for a left knee length discrepancy. Those latter ratings are not at issue herein. Diagnostic Code 5314 pertains to a disability of Muscle Group XIV, which is comprised of the anterior thigh group: 1) sartorius, 2) rectus femoris, 3) vastus externus, 4) vastus intermedius, 5) vastus internus, and tensor vaginae femoris. The functions of Muscle Group XIV include: extension of the knee; simultaneous flexion of the hip and flexion of the knee; tension of fascia lata and iliotibial (Maissiat’s band) acting with Muscle Group XVII in postural support of the body; and acting with the hamstrings in synchronizing the hip and knee. A slight disability warrants a noncompensable rating. A moderate disability warrants a 10 percent disability rating. A moderately severe disability warrants a 30 percent disability rating. A severe disability warrants a 40 percent rating, the highest rating available under the diagnostic code. Diagnostic Code 5314. 1. Entitlement to service connection for bilateral neuropathy of the feet, to include as secondary to service connected left knee disorder The Veteran contends that his bilateral neuropathy of the feet is proximately related to his service connected left knee disorder. The Veteran’s service treatment records (STRs) are negative for any complaints, diagnosis, or treatments for neuropathy bilaterally of the feet. At the Veteran’s examination prior to discharge, the examiner noted no neuropathy of the feet. The Veteran denied any pertinent findings. VA examinations were conducted in1963 and 1968. They are negative for any pertinent complaints or findings. The Veteran raised other concerns during these examinations. March 2009 VA outpatient treatment records reveal that the Veteran reported numbness in his toes bilaterally. The Veteran also reported that the numbness was present for over a year. November 2014 VA outpatient treatment records reveal that the examiner noted numbness of the feet bilaterally. In a November 2020 VA peripheral nerve examination, the examiner diagnosed the Veteran with neuropathy of the feet. The examiner opined that the Veteran’s bilateral lower extremity peripheral neuropathy is less likely due to any in-service event or injury. He explained that with the exception of an August 1960 in-service examination which diagnosed aching feet while walking, there is no evidence of foot symptoms noted in the Veteran’s STRs. The examiner also explained that generally, the symptoms of peripheral neuropathy are not associated with walking and include numbness, tingling as well as pain. The examiner also opined that the Veteran’s bilateral neuropathy of the feet is less likely than not proximately related to the Veteran’s service connected left knee disorder. The examiner noted that the Veteran has a diagnosis of peripheral neuropathy of the uninjured right lower extremity which does not support a causal factor between the knee injury and the peripheral neuropathy. To summarize the Veteran’s STRs do not reveal any complaints, diagnosis, or treatments for bilateral neuropathy of the feet. Furthermore, there is also no indication of any complaints or treatments for any feet disorders related to service or until many several years post-service. See Mason v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is evidence against a claim of service connection). This premise is further evidenced by the fact that the Veteran did not submit a compensation and pension application for his service-related bilateral neuropathy of the feet until many years after separation from service. In fact, the initial claim for disability compensation did not include reference to the bilateral neuropathy of the feet. The examiner also opined that the Veteran’s peripheral neuropathy is less likely than not aggravated beyond its natural progression due to his service connected left knee disorder. The examiner explained that a left knee injury is not a well-defined exacerbation factor for progression of axonal peripheral neuropathy that is bilateral. The foregoing summary of the treatment record reveals no possibility for service connection for bilateral neuropathy of the feet, to include as secondary to a service connected left knee disorder on a secondary basis. Although the Veteran contends that his reported chronic venous insufficiency disorder is related to his service connected left knee disorder, there is no evidence in the record of treatment in-service for chronic bilateral neuropathy of the feet. The Board does acknowledge that the Veteran experiences chronic bilateral neuropathy of the feet; however, as determined by the November 2020 examiner, there is not a significant correlation between the Veteran’s chronic bilateral neuropathy of the feet and his time in-service as related to his service connected left knee disorder. Moreover, the November 2020 VA examiner explained that generally, the symptoms of peripheral neuropathy are not associated with walking and include numbness, tingling as well as pain. The examiner also explained that the Veteran has a diagnosis of peripheral neuropathy of the uninjured right lower extremity which does not support a causal factor between the knee injury and the peripheral neuropathy. The Board also reviewed the Veteran’s lay statements asserting that the onset of his bilateral neuropathy of the feet was caused by his service connected left knee disorder. Lay people are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses. However, the Board must emphasize that the Veteran is not competent to interpret accurately clinical findings pertaining to a bilateral neuropathy of the feet disorder as this requires highly specialized knowledge and training. 38 C.F.R. § 3.159 (a)(1) (2018). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). As a pathology for the onset of a bilateral neuropathy of the feet disorder has not been shown to be related to the Veteran’s service-connected left knee disorder, the Board concludes that the clinical evidence does not support the Veteran’s contentions for a granting of service connection on a secondary basis. Based on this evidence, the Board finds service connection is not warranted. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claim, the doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 4.3 (2020). 2. Entitlement to service connection for tinnitus The Veteran contends that his tinnitus is related to his noise exposure in-service. The Veteran’s military personnel records indicate that his military occupational specialty was a radio repairman man. The Board concedes moderate in-service noise exposure. STRs are bare for any complaints, diagnosis, or treatments for tinnitus. At the Veteran’s examination prior to discharge, the examiner noted that the Veteran’s hearing tested normal with no signs of acoustic trauma. The Veteran denied ear trauma, ringing of the ears, or running ears at discharge. Again, VA examinations were conducted in 1963 and 1968. The Veteran had other complaints but no complaints of findings of hearing loss, ear problems, or tinnitus were demonstrated on these exams. April 2014 VA outpatient treatment records indicate that the Veteran presented with complaints of ringing in his ears. The examiner noted that the Veteran’s left ear was clear, but his right ear was 80 percent blocked with ear wax. There was no evidence of an ear infection. Tinnitus management was prescribed. In an October 2020 VA tinnitus examination, the examiner diagnosed the Veteran with tinnitus. The examiner opined that it is less likely than not that the Veteran’s tinnitus was caused by or the result of military noise exposure. The examiner explained that medical records reveal a MOS of Radio Repairman which carried a moderate probability of noise exposure. The examiner explained that a separation audiogram demonstrates normal hearing thresholds bilaterally. The examiner determined that although the Veteran has reported constant bilateral tinnitus during active service, there is no nexus of auditory damage in-service to relate his current tinnitus to in-service noise exposure. The Board also reviewed the Veteran's lay statements that his tinnitus is connected to his exposure to noise exposure in-service. Lay people are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses. However, the Board must emphasize that the Veteran is not competent to interpret accurately clinical findings pertaining tinnitus as this requires highly specialized knowledge and training. 38 C.F.R. § 3.159 (a)(1). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Here the pertinent history is of the noted onset after service, without complaints or findings shown in service that are suggestive of hearing loss or tinnitus. It is determined that the Veteran’s recall is less persuasive that the medical evidence which does not show hearing impairment or tinnitus complaints during service or on the post-service exams conducted in the years following service. While the Veteran has reported that his tinnitus has been present since service, this is not found to be persuasive considering the other evidence of the record. It has been determined by the Board that the Veteran’s tinnitus is not the result of noise exposure or acoustic trauma in-service. As evidenced by the October 2020 examiner opinion, the Veteran’s STRs prior to discharge do not reveal any complaints, diagnoses, or treatments for tinnitus related to acoustic trauma or noise exposure. Moreover, the Veteran did not report any ringing or bleeding of the ears in-service. Furthermore, there are no clinical treatment records showing the Veteran was treated for tinnitus for many years after discharge. See Mason v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is evidence against a claim of service connection). This premise is further evidenced by the fact that the Veteran did not submit a compensation form for tinnitus until many years after separation from service. In sum the Board finds the October 2020 VA examiners opinion to be probative and compelling. The Board finds that the onset of the Veteran’s tinnitus disorder is not the result of in-service noise exposure or acoustic trauma. The more probative evidence suggests it is due to non-service-related causes after his discharge from service. Based on this evidence, the Board finds service connection is not warranted. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claim, the doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 4.3. 3. Entitlement to an increased evaluation in excess of 10 percent for the residuals of a gunshot wound to the left knee The Veteran contends that he is entitled to an increased rating in excess of 10 percent for the residuals of a gunshot wound to the left knee caused to Muscle Group XIV. Service and immediate post-service medical records reveal that the Veteran sustained an accidental gunshot wound to the left thigh and knee when cleaning his rifle. He was hit with a 22 caliber bullet that entered the upper aspect of the patella and exited below it. On post-service exam it was noted the wounds were well healed and there was no attachment to deep structures. Subsequent to these findings a 10 percent rating for moderate damage to Muscle Group XIV was assigned. In a December 2014 VA muscle injuries examination, the examiner diagnosed the Veteran with the residuals of a gunshot wound to the Muscle Group XIII posterior thigh/ hamstring muscle of the lower left extremity and Muscle Group XIV anterior thigh muscle of the lower left extremity. The examiner noted that the Veteran does not currently have a non-penetrating muscle injury in the area of the wound; however, the examiner did diagnose a minimal scar in the area of the Veteran’s healed gunshot wound. The scar did not impair the Veteran’s ability to walk. The Veteran reported no muscle weakness. Muscle strength testing was noted as normal with no evidence of atrophy. There was also no evidence of pain with weight-bearing, localized tenderness, or pain on palpation. The Veteran reported the use of a cane as an assistive device. X-ray findings reveal no evidence of remaining shell fragments or shrapnel in the left knee. Concerning functional and occupational impairment the examiner noted that the Veteran has difficulty walking, sitting, and squatting due to his left knee pain. In a September 2017 VA muscle injuries examination, the examiner diagnosed the Veteran with the residuals of a gunshot wound to the Muscle Group XIII posterior thigh/ hamstring muscle of the lower left extremity and Muscle Group XIV anterior thigh muscle of the lower left extremity. The examiner noted that the Veteran does not currently have a non-penetrating muscle injury in the area of the wound; however, the examiner did diagnose a minimal scar in the area of the Veteran’s healed gunshot wound that is neither painful or unstable. The scar did not impair the Veteran’s ability to walk. The Veteran reported no muscle weakness. Muscle strength testing was noted as normal with no evidence of atrophy. There was also no evidence of pain with weight-bearing, localized tenderness, or pain on palpitation. The Veteran reported the use of a cane occasionally and knee brace regularly as an assistive device. X-ray findings reveal no evidence of remaining shell fragments or shrapnel. Concerning functional and occupational impairment the examiner noted that the Veteran requires a sedentary position. In a November 2020 VA muscle injuries examination, the examiner diagnosed the Veteran with the residuals of a gunshot wound to the Muscle Group XIV anterior thigh muscle of the lower left extremity. The examiner noted that the Veteran does not currently have a non-penetrating muscle injury in the area of the wound; however, the examiner did diagnose a minimal scar in the area of the Veteran’s healed gunshot wound that is neither painful or unstable. The examiner noted that the Veteran’s course of the left knee gunshot wound has remained the same and not worsened. The scar did not impair the Veteran’s ability to walk. The examiner diagnosed loss of muscle power, muscle weakness, and muscle fatigue. Muscle strength testing was noted as normal with no evidence of atrophy. There was also no evidence of pain with weight-bearing, localized tenderness, or pain on palpation. The Veteran reported the use of a cane constantly as an assistive device. X-ray findings reveal no evidence of remaining shell fragments or shrapnel. Concerning functional and occupational impairment the examiner noted that the Veteran is limited in prolonged standing and climbing stairs. Upon review of the evidence, the Board finds that higher ratings are not warranted for the Veteran’s muscle injury. The wound on the left thigh is no more than moderate in severity, thus warranting the current 10 percent disability rating for Muscle Group XIV. While there has been mention of Muscle Group XIII involvement, this does not appear to be to a compensable degree given the initial and more recent post-service findings. The primary involvement appears to be to Muscle Group XIV and is of a moderate degree. The Veteran reported pain and stiffness but denied weakness and mild functional impairment, at worst. Muscle function loss was diagnosed as normal. Based upon these symptoms, there is a moderate muscle injury. Again, there is no debridement, sloughing of soft parts, intermuscular scarring, or a history of prolonged infection. Although there is some pain and fatigue, strength has remained normal, and there is no evidence of incoordination and/or uncertainty of movement. The elevated degree of symptoms expected for a moderately severe injury are not present to assign a 30 percent disability rating. Therefore, the assigned 10 percent rating adequately contemplates the impairment resulting from this disability. See 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). 4.Entitlement to service connection for a respiratory disorder The Veteran also contends that a pre-existing bronchial disorder diagnosed at his entrance examination was aggravated beyond its natural progression by his time in-service. October 1961 STRs radiological findings reveal findings of cystic disease or bullous emphysema bilaterally. There is no evidence noted at the Veteran’s examination prior to discharge of any worsening of his pre-existing respiratory disorder. In an April 1963 VA examination, the Veteran reported trouble breathing. Radiological findings reveal clear lungs with normal sinuses. Respiration was also noted as normal. The examiner diagnosed the Veteran with rhinitis and pharyngitis with telangiectasia of the post-pharyngeal wall. (As noted, this pathology has been service connected.) No pertinent complaints or findings were recorded on the 1968 examination. March 2009 VA outpatient treatment records reveal that the Veteran presented with complaints of pain in his right lung. He also reported coughing up blood. The Veteran underwent pulmonary testing. FEV1 and FVC were noted as supernormal. In a December 2014 VA respiratory examination, the examiner diagnosed the Veteran with allergic rhinitis with an onset date of 1980. March 2019 private treatment records reveal that the Veteran was diagnosed with obstructive sleep apnea. December 2019 VA private treatment records reveal that the Veteran presented with shortness of breath. Imaging findings were negative for a pulmonary embolism. In a November 2020 VA respiratory conditions examination, the examiner diagnosed the Veteran with mild obstructive airway disease. The examiner opined that the Veteran’s respiratory disorder is less likely than not related to an in-service event, injury, or illness. He explained that while the in-service October 1961 physical notes large cysts/bulla in the upper left lobe the Veteran did report dyspnea that is not consistent with the current x-rays which shows a linear scar if the left lung base without any left upper lobe findings. The examiner determined that it is most likely that the pre-existing bullous emphysema resolved in-service. The examiner explained that the current obstructive pattern is also responsive to bronchodilators which would not be noted with bullous emphysema. The Board also reviewed the Veteran’s lay statements asserting that the onset of his respiratory disorder was aggravated by is time in-service. Lay people are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses. However, the Board must emphasize that the Veteran is not competent to interpret accurately clinical findings pertaining to a respiratory disorder of the lower extremities as this requires highly specialized knowledge and training. 38 C.F.R. § 3.159 (a)(1) (2018). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Here, there is no competent evidence to show an in-service increase or aggravation of the Veteran’s respiratory disorder. As indicated above, there is also no indication of any complaints or treatments for the aggravation of a respiratory disorder related to service or for several years post-service. See Mason v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is evidence against a claim of service connection). While the Veteran has reported that his pre-existing respiratory disorder was aggravated by his time in-service, this is not found to be persuasive considering the other evidence of the record. In sum, the Veteran’s STRs establish a respiratory disorder as existing prior to service. The Veteran presented with complaints in-service and received treatment. There is no evidence noted at the Veteran’s examination prior to discharge of any worsening of his pre-existing respiratory disorder. Moreover, as indicated by the November 2020 examiner findings, the examiner determined that it is most likely that the Veteran’s pre-existing bullous emphysema resolved itself in-service. He explained that while the in-service October 1961 physical notes a large cysts/bulla in the upper left lobe the Veteran did report dyspnea which is not consistent with the current x-rays which shows a linear scar of the left lung base without any left upper lobe findings. For these reasons, the Board finds that more likely than not there is no competent evidence to show a measured worsening of the Veteran’s pre-existing respiratory disorder during active service. Moreover, the Veteran has not met his burden to show an increase or aggravation of his pre-existing respiratory disorder during active service. With no competent evidence to show an increase in severity of the pre-existing respiratory disorder during service, the presumption of aggravation does not arise. As such, a discussion of clear and unmistakable evidence to rebut the presumption of aggravation is not required. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). Accordingly, claim for service-connection is denied. 5. Entitlement to service connection for a vascular disorder of the lower extremities, to include as secondary to service connected left knee disorder The Veteran contends that his vascular disorder of the lower extremities is proximately related to his service connected left knee disorder. STRs are negative for any complaints, diagnosis, or treatments for any vascular disorder of the lower extremities. At the Veteran’s examination prior to discharge, the examiner noted no vascular disorders of the lower extremities. The Veteran denied any clots, or vascular problems of his lower extremities. The 1963 examination is negative for pertinent findings. Bilateral varicosities were observed on examination in 1968. No cause for the pathology was set out. October and November 2014 VA outpatient treatment records reveal that the Veteran underwent a venous insufficiency study for varicose veins. The examiner diagnosed the Veteran as negative for deep or superficial vein thrombus; however, the examiner diagnosed deep superficial vein reflux bilaterally of the lower extremities. In a November 2020 VA examination, the examiner diagnosed the Veteran with varicose veins of the bilaterally of lower extremities. The examiner opined that the Veteran’s varicose veins are less likely than not related to an in-service event or injury. The examiner explained that the STRs dated August 1960 notes pain in feet while walking, but a physical exam does not note objective findings of varicose veins. There were also no findings of varicose veins during the Veteran’s enlistment exam prior to service in the military. The examiner opined that it is less than likely that the Veteran’s varicose veins are proximately due to his service connected left knee disorder. The examiner explained that the varicose veins are noted on both lower extremities which does not support the left knee injury having a role in proximately causing the onset of the Veteran’s varicose veins. The examiner noted that if the Veteran’s left knee was the cause, he would not be expected to note varicose veins in the lower right extremity. The examiner determined that the Veteran’s age and predisposition for the condition are the more likely causal factors which caused the onset of the Veteran’s varicose veins. To summarize the Veteran’s STRs do not reveal any complaints, diagnosis, or treatments for a vascular disorder of the lower extremities. Furthermore, there is also no indication of any complaints or treatments for any vascular disorders related to service or for several years post-service. See Mason v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is evidence against a claim of service connection). This premise is further evidenced by the fact that the Veteran did not submit a compensation and pension application for his vascular disorder of the lower extremities until many years after separation from service. In fact, the initial claim for disability compensation did not include reference to the vascular disorder of the lower extremities. Therefore, the foregoing summary of the treatment record reveals no possibility for service connection for a vascular disorder of the lower extremities on a secondary basis. Although the Veteran contends that his reported vascular disorder of the lower extremities is related to his service connected left knee disorder, there is no evidence in the record of treatment in-service for a vascular disorder of the lower extremities. Moreover, the November 2020 VA examiner explained that varicose veins are noted on both lower extremities which does not support the left knee injury having a role in proximately causing the onset of the Veteran’s varicose veins. The examiner also noted that if the Veteran’s left knee disorder was the cause, he would not be expected to have varicose veins in the lower right extremity. Lastly, the examiner determined that the Veteran’s age and predisposition for the development of varicose is the more likely the causal factors which caused the onset of the Veteran’s varicose veins. The Board also reviewed the Veteran’s lay statements asserting that the onset of his vascular disorder of the lower extremities was caused by his service connected left knee disorder. Lay people are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses. However, the Board must emphasize that the Veteran is not competent to interpret accurately clinical findings pertaining to a vascular disorder of the lower extremities as this requires highly specialized knowledge and training. 38 C.F.R. § 3.159 (a)(1) (2018). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). As a pathology for the onset of the Veteran’s vascular disorder of the lower extremities has not been shown to be related to his service connected left knee disorder, the Board concludes that the clinical evidence does not support the Veteran’s contentions for a granting of service connection on a secondary basis. Based on this evidence, the Board finds service connection is not warranted. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does   not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claim, the doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107 (b) (2012); 38 C.F.R. § 4.3 (2020). MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Elliot Harris 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.