Citation Nr: 21020743 Decision Date: 04/08/21 Archive Date: 04/08/21 DOCKET NO. 14-06 925 DATE: April 8, 2021 ORDER Entitlement to service connection for obstructive sleep apnea is granted. Entitlement to service connection for gout and/or generalized arthritis is denied. Entitlement to service connection for a left leg disability is denied. Entitlement to service connection for a right leg/right ankle disability is denied. Entitlement to service connection for a skin disability of the feet is denied. Entitlement to service connection for a bilateral foot disability is denied. Entitlement to service connection for carpal tunnel syndrome is denied. Entitlement to service connection for acid reflux is denied. Entitlement to service connection for hemorrhoids is denied. Entitlement to service connection for poor circulation/venous insufficiency is denied. Entitlement to service connection for a headache disability is denied. Entitlement to service connection for jock itch is denied. Entitlement to service connection for moles is denied. REMANDED Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for a bilateral knee disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for asthma, to include as secondary to posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for chronic fatigue syndrome, to include as secondary to obstructive sleep apnea, is remanded. Entitlement to service connection for a sinus disability is remanded. Entitlement to service connection for chronic bronchitis is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in his favor, the Veteran’s obstructive sleep apnea is caused or aggravated by his service-connected PTSD. 2. The Veteran’s gout did not manifest during active service, generalized arthritis did not manifest within one year of discharge from active service, and there is no indication that his gout or gouty arthritis are otherwise related to his active service. 3. The Veteran’s left leg disability did not manifest during active service, and there is no indication that it is causally related to active service. 4. The Veteran’s right leg/right ankle disability did not manifest during active service, arthritis did not manifest within one year of discharge from active service, and there is no indication that his current right leg/ankle disability is otherwise related to his active service. 5. The Veteran’s skin disability of the feet did not manifest during active service, and there is no indication that it is otherwise related to his active service or a service-connected disability. 6. The Veteran’s bilateral foot disability did not manifest during active service, and there is no indication that it is causally related to active service. 7. The Veteran’s carpal tunnel syndrome did not manifest during active service, and there is no indication that it is causally related to active service. 8. The Veteran’s acid reflux did not manifest during active service, and there is no indication that it is causally related to active service. 9. The Veteran’s hemorrhoids did not manifest during active service, and there is no indication that they are causally related to active service. 10. The Veteran’s poor circulation/venous insufficiency did not manifest during active service, and there is no indication that it is causally related to active service. 11. The Veteran’s headache disability did not manifest during active service, and there is no indication that it is causally related to active service. 12. The Veteran’s jock itch did not manifest during active service, and there is no indication that it is causally related to active service. 13. The Veteran’s moles did not manifest during active service, and there is no indication that they are causally related to active service. CONCLUSIONS OF LAW 1. The criteria for service connection for obstructive sleep apnea are met. 38 U.S.C. §§ 1110, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 2. The criteria for service connection for gout/generalized arthritis are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 3. The criteria for service connection for a left leg disability are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). 4. The criteria for service connection for a right leg/right ankle disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 1137, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 5. The criteria for service connection for a skin disability of the feet are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2020). 6. The criteria for service connection for a bilateral foot disability are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). 7. The criteria for service connection for carpal tunnel syndrome are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). 8. The criteria for service connection for acid reflux are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). 9. The criteria for service connection for hemorrhoids are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). 10. The criteria for service connection for poor circulation/venous insufficiency are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). 11. The criteria for service connection for a headache disability are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). 12. The criteria for service connection for jock itch are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). 13. The criteria for service connection for moles are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active naval service from October 1986 to October 1990. This case initially came before the Board of Veterans’ Appeals (Board) on appeal from a November 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. In April 2018, the Veteran and his daughter testified before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In July 2018, the Board remanded the claims to the Agency of Original Jurisdiction (AOJ) for additional development. The case has since been returned to the Board. The Veteran also appealed the issue of entitlement to service connection for hypertension. In an October 2020 rating decision, the AOJ granted service connection for that disability, which constitutes a full award of the benefits sought on appeal. See Grantham v. Brown, 114 F. 3d 1156, 1158 (Fed. Cir. 1997). Thus, that matter is no longer in appellate status. Service Connection – Sleep Apnea The Veteran maintains that his sleep apnea was incurred in or is related to service. Alternative, he contends that his sleep apnea is caused or aggravated by his service-connected PTSD. During the April 2018 Board hearing, the Veteran stated that he had difficulty sleeping during service because of the noise. He stated that he told the medic corpsman that it was difficult for him to lie on his back because he would feel choked. He also reported snoring during service. The Veteran’s service treatment records are unremarkable for any complaints, treatment, or diagnoses related to sleep apnea. At his September 1990 separation examination, he denied having frequent trouble sleeping. Post service, a July 2009 private treatment record noted that the Veteran had obstructive sleep apnea. In this case, there is evidence for and against the Veteran’s claim. As discussed below, resolving reasonable doubt in his favor, the Board finds that service connection for obstructive sleep apnea is warranted. In an October 2015 letter, a private nurse practitioner, B.C., noted that the Veteran had been treated for sleep apnea since July 2009. He opined that it was more than likely that his conditions were a direct result of his military service. He offered no rationale for his opinion. Therefore, the opinion has little, if any, probative weight. In an October 2015 letter, a private psychologist, Dr. K.S., opined that the Veteran’s service-connected PTSD and sleep apnea were causally interactive with each other on a continuous basis, each complicating and worsening the effects of the other. He noted that PTSD itself created a severe sleep disturbance in sleep quality, which was magnified by sleep apnea and that his sleep apnea problem was magnified by his PTSD’s sleep disturbance. In a March 2016 letter, he stated that research had demonstrated that sleep apnea is a common correlate of underlying PTSD. In a December 2016 letter, he stated that he had determined that the Veteran’s PTSD was a major causal component of his obstructive sleep apnea, noting that his PTSD caused him to suffer from a severe sleep disturbance with nightmares, and that there was clinical evidence that patients suffering from such sleep disturbances were more likely than the general population to have sleep apnea. He reiterated this opinion again in a March 2021 letter. In addition, the Veteran submitted several journal articles regarding PTSD and sleep apnea. A November 2005 article noted that sleep apnea was associated with a higher prevalence of psychiatric comorbid conditions. A November 2012 article noted that the medical community was increasingly concerned about the growing number of veterans suffering from obstructive sleep apnea. It was noted that some doctors believed the prevalence was due to multiple deployments to Iraq and Afghanistan and being exposed to higher levels of dust, smoke, stress, and violence. It was also noted that veterans with PTSD and depression were more likely to report obstructive sleep apnea. A July 2013 article indicated that a study suggested that CPAP therapy reduced nightmares in veterans with PTSD. With regard to medical treatise evidence, such evidence “can provide important support when combined with an opinion of a medical professional” if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least “plausible causality” based upon objective facts rather than on an unsubstantiated lay medical opinion. Sacks v. West, 11 Vet. App. 314 (1998); see also Wallin v. West, 11 Vet. App. 509 (1998). In this case, the medical articles submitted by the Veteran are accompanied by Dr. K.S.’s medical opinion. Therefore, when taken together, they are significantly probative evidence weighing in favor of the claim. The evidence against the Veteran’s claim consists of medical opinions from December 2016 and August 2020 VA examiners. The December 2016 VA examiner opined that the Veteran’s sleep apnea was less likely than not incurred in or related to service, noting that although some medical studies showed a high incidence of sleep apnea associated with PTSD in soldiers returning from the Gulf War, those studies have not established a definitive cause and effect relationship between PTSD and the development of obstructive sleep apnea. The August 2020 VA examiner opined that the Veteran’s sleep apnea was less likely than not incurred in or caused by service, noting that there was insufficient objective data to support a connection between his post-service sleep apnea and any sleep issues he had in service. The Board finds those medical opinions probative, but not more so than the opinions provided by Dr. K.S. along with the medical journal articles. In this case, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s sleep apnea was caused or aggravated by his service-connected PTSD. 38 C.F.R. § 3.310. Therefore, resolving reasonable doubt in his favor, the claim for service connection for obstructive sleep apnea is granted. 38 U.S.C. § 5107(b) (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service Connection - Gout/Generalized Arthritis The Veteran’s service treatment records are unremarkable for any complaints, treatment, or diagnoses related to gout or generalized arthritis. At his September 1990 separation examination, his upper and lower extremities, spine, and musculoskeletal system were normal. On his Report of Medical History, he denied any bone, joint, or other deformity. On an October 1990 dental health questionnaire, he denied having a history of arthritis or painful joints. Post service, an August 2005 private treatment record indicated that the Veteran complained of gout in his right ankle. It was noted that he had gone to the emergency room the previously week and was diagnosed with gout. Later records note treatment for gout and gouty arthritis. In an October 2015 letter, a private nurse practitioner, B.C., noted that the Veteran had been treated for hypertension, hyperlipidemia, insulin-dependent diabetes mellitus, PTSD, arthritis, and sleep apnea since July 2009. He opined that it was more than likely that his conditions were a direct result of his military service. He offered no rationale for his opinion. Therefore, the opinion has little, if any, probative weight. During an August 2020 VA examination, the Veteran reported that he was diagnosed with gout in approximately 2008, after he separated from service. He stated that he had recurrent swelling in the great toes of both feet. The examiner opined that the claimed condition was less likely than not incurred in or caused by service, noting that there was insufficient evidence to support any causal relationship between any post-service gout and/or generalized arthritis and service, noting that there were no in-service symptoms or diagnostic information to support such a relationship. In this case, the Board finds the most probative evidence weighs against the claim. The evidence does not indicate that the Veteran’s gout manifested during active service. After service, the first documentation of gout occurred in August 2005, over 14 years after discharge. The passage of time between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Furthermore, the August 2020 VA examiner opined that the Veteran’s gout was less likely than not related to service. The examiner considered and addressed the relevant evidence of record, the Veteran’s contentions, and provided rationale for his opinion. For this reason, the Board finds the VA examiner’s opinion significantly probative. The only medical opinion supporting the Veteran’s claim is the October 2015 opinion from B.C., which the Board finds has little, if any, probative value. The nurse practitioner provided no rationale for his conclusion that the Veteran’s arthritis was related to service. The Board has also considered the lay evidence of record. The Veteran is competent to describe what he has personally observed or experienced. However, the ultimate questions of diagnoses and etiology in this case extend beyond an immediately observable cause-and-effect relationship and are beyond the competence of lay witnesses. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for gout or generalized arthritis is not warranted. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 49. Service Connection – Left Leg The Veteran maintains that he left leg disability was incurred in or aggravated by active service. During the April 2018 Board hearing, he stated that when he was out at sea, his left leg began bothering him where he had fractured it as a child. He stated that he gets a tender spot where the fracture happened. He reported that it was worse in cold weather or with activity like going up stairs. The Veteran’s June 1986 enlistment examination report noted that his lower extremities were normal. On his Report of Medical History, it was noted that he fractured his left tibia at age 10, that his leg was casted and that there were no sequelae. In August 1988, he complained of soreness and pain in left leg at the previous fracture site. It was noted that pain and discomfort was felt whenever pressure was applied. Swelling and tenderness was noted without obvious deformity. Range of motion was within normal limits. The assessment was contusion. X-rays showed no obvious fracture or soft tissue densities. He was given hot compresses and Tylenol and returned to full duty. A June 1989 record noted that he hit his lower left leg while entering the shower and had pain and swelling with prolonged standing. It was noted that he had mild edema to the mid lateral lower leg. The assessment was contusion. He was given an Ace bandage and instructed to avoid prolonged standing for three days. At his September 1990 separation examination, his lower extremities were normal, and he denied bone, joint, or other deformity. It was noted that he had fractured a bone in his left leg when he was 10 years old and that it had healed and was not considered disabling Post service, an April 2010 VA treatment record noted that the Veteran complained of throbbing pain in his arms and legs and weakness after use for long periods. It was noted that he was being worked up for a myopathy by neurology. A November 2010 private treatment record noted that the Veteran had a muscle biopsy done in his left leg secondary to extreme muscle weakness. A VA examination was conducted in August 2020. The examiner opined that the claimed condition was less likely than not incurred in or caused by service, noting that there was insufficient evidence to support any causal relationship between any left leg issues during service and any post-service left leg disability. In this case, the Board finds the most probative evidence weighs against the claim. The evidence indicates the Veteran fractured his left leg prior to service and that it healed without residuals. During service, he sustained contusions of the left leg; however, the evidence does not indicate that there was any resulting chronic disability or aggravation of the prior fracture. At his September 1990 separation examination, his lower extremities were normal, and he denied any bone, joint, or other deformity. Post service, the first documented complaints of chronic pain and weakness in his legs was in April 2010, over nine years after discharge. The passage of time between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson, 230 F.3d at 1333. Furthermore, the August 2020 VA examiner opined that the Veteran’s claimed left leg disability was less likely than not related to service. The examiner considered and addressed the relevant evidence of record, the Veteran’s contentions, and provided rationale for his opinion. For this reason, the Board finds the VA examiner’s opinion significantly probative. Furthermore, there are no medical opinions to the contrary. The Board has also considered the lay evidence of record. The Veteran is competent to describe what he has personally observed or experienced. However, the ultimate questions of diagnoses and etiology in this case extend beyond an immediately observable cause-and-effect relationship and are beyond the competence of lay witnesses. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for a left leg disability is not warranted. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 49. Service Connection – Right Leg/ Right Ankle The Veteran maintains that his right leg/right ankle disability was incurred in or related to service. During the April 2018 Board hearing, he stated that he had poor circulation, right knee, and right ankle problems; however, he did not identify a separate right leg disability. He stated that he sprained his right ankle during service. A December 1988 service treatment record indicated that the Veteran injured his right ankle playing basketball. It was noted that he inverted his right ankle against full weight and was able to partially bear weight following the injury. He stated that he sprained his right ankle three times previously. It was noted that he was favoring his right ankle and that there was edema and tenderness over the right lateral malleolus. The assessment was right ankle sprain. At his September 1990 separation examination, his lower extremities were normal, and he denied any bone, joint, or other deformity. Post service, an August 2005 private treatment record indicated that the Veteran had gout in his right ankle. The report of an August 2020 VA examination indicated that the Veteran reported that he was diagnosed with degenerative arthritis and ankle sprain in approximately 1987. The examiner opined that the claimed condition was less likely than not incurred in or caused by service, noting that there was insufficient evidence to support any causal relationship between any post-service right ankle disability and service, noting that at his September 1990 separation examination, there was no right ankle disability documented and no complaints of any right ankle problems. In this case, the Board finds the most probative evidence weighs against the claim. Although the Veteran sprained his right ankle during service in December 1988, there were no follow-up records of treatment and his September 1990 separation examination did not indicate that he had any right ankle problems or complaints. This suggests that the sprain he sustained during service was acute and transitory and did not result in chronic disability. Post service, the first documented complaints of any right ankle problem was in August 2005, over 14 years after discharge. The passage of time between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson, 230 F.3d at 1333. Furthermore, the August 2020 VA examiner opined that the Veteran’s right ankle disability was less likely than not related to service. The examiner considered and addressed the relevant evidence of record, the Veteran’s contentions, and provided rationale for his opinion. For this reason, the Board finds the VA examiner’s opinion significantly probative. The only medical opinion supporting the Veteran’s claim is the October 2015 opinion from B.C., which the Board finds has little, if any, probative value. The nurse practitioner provided no rationale for his conclusion that the Veteran’s arthritis was related to service. The Board has also considered the lay evidence of record. The Veteran is competent to describe what he has personally observed or experienced. However, the ultimate questions of diagnoses and etiology in this case extend beyond an immediately observable cause-and-effect relationship and are beyond the competence of lay witnesses. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for a right leg/right ankle disability is not warranted. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 49. Service Connection – Skin Disability of the Feet The Veteran maintains that he has a skin disability of the feet that was incurred in or related to service. During the April 2018 Board hearing, he stated that he had athlete’s feet during service and that he went to sick call. He stated that he has continued to have problems with athlete’s feet on and off since service, especially in the summer. The Veteran’s service treatment records are unremarkable for any complaints, treatment, or diagnoses related to a skin disability of the feet. At his September 1990 separation examination, his skin and feet were normal, and he denied having any skin diseases or foot trouble. Post service, a November 2010 private treatment record indicated that the Veteran complained of athlete’s foot, which he stated was from the military. He requested a letter from his physician stating that his condition was related to the military. The physician stated that it was not caused by the military and that everyone was exposed to fungus, but that some people are more susceptible to flares than others. VA treatment records note tinea pedis on the Veteran’s active problems list beginning in November 2012. In an October 2015 letter, a private podiatrist, Dr. E.T., stated that she had been treating the Veteran for fungal infection/dermatitis of the feet. She opined that it was more likely than not that the condition was caused by conditions encountered during service. She provided no rationale for her opinion. Therefore, the opinion has little, if any, probative weight. In a December 2016 letter, a private psychologist, Dr. K.S., opined that the Veteran’s chronic fungal infection of his feet was causally related and/or interactive with his PTSD; however, he provided no rationale for his opinion. Therefore, the opinion has little, if any, probative weight. The report of an August 2020 VA examination indicated that the Veteran reported that he began having problems with athlete’s foot in approximately 1987. On examination, athlete’s foot was not present; however, it was noted that he had onychomycosis of the first and second digits of both feet. He attributed the problem to wearing boots. The examiner opined that the claimed condition was less likely than not incurred in or caused by service, noting that there was insufficient evidence to support any causal relationship between any post-service skin problems of the feet and service, noting that at his September 1990 separation examination, his skin was normal, and he denied having any skin diseases. The examiner also opined that it was less likely than not that onychomycosis was caused or aggravated by PTSD, noting that the skin disability was a physiological and/or anatomic condition and that the latter was a psychological condition. In this case, the Board finds the most probative evidence weighs against the claim. Although the Veteran reported that his athlete’s foot disability began during service, his service treatment records do not indicate he had any complaints or treatment for the condition. Furthermore, at his September 1990 separation examination, his skin and feet were normal, and he denied having any skin diseases. Post service, the first documented complaints of any skin problems related to the feet was in November 2010, over 20 years after discharge. The passage of time between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson, 230 F.3d at 1333. Furthermore, the August 2020 VA examiner opined that the Veteran’s skin disability of the feet was less likely than not related to service and was not caused or aggravated by PTSD. The examiner considered and addressed the relevant evidence of record, the Veteran’s contentions, and provided rationale for his opinion. For this reason, the Board finds the VA examiner’s opinion significantly probative. The only medical opinions supporting the Veteran’s claim are the October 2015 and December 2016 opinions from a private podiatrist and private psychologist, which the Board finds have little, if any, probative value. The treatment providers offered no rationale for their conclusions that the Veteran’s skin disability of the feet was related to service or a service-connected disability. The Board has also considered the lay evidence of record. The Veteran is competent to describe what he has personally observed or experienced. However, the ultimate questions of diagnoses and etiology in this case extend beyond an immediately observable cause-and-effect relationship and are beyond the competence of lay witnesses. Accordingly, the Board finds that the preponderance of the evidence is against the claim and entitlement to service connection for a skin disability of the feet is not warranted. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 49. Service Connection – Bilateral Foot, Carpal Tunnel Syndrome, Acid Reflux, Hemorrhoids, Poor Circulation, Migraine Headaches, Jock Itch, and Moles The Veteran maintains that he his current bilateral foot disability, carpal tunnel syndrome, acid reflux, hemorrhoids, poor circulation, migraine headaches, jock itch, and moles were incurred in or are related to active service. During the April 2018 Board hearing, the Veteran stated that he was wearing orthotics for flat feet. He stated that he began having foot pain during service and that he bought some Dr. Scholl’s inserts and put them in his boots. He stated that it helped a bit but that the arches of his feet continued to hurt. He also stated that his carpal tunnel syndrome began when he was typing every day during service and that his acid reflux, hemorrhoids, headaches, and jock itch also began during service. Regarding poor circulation and swelling in his legs, he stated that he was diagnosed after service in 2007 or 2008. Regarding moles, he stated that he had one mole from birth, but that he started growing additional moles while he was out to sea in the Navy. The Veteran’s service treatment records are unremarkable for any complaints, treatment, or diagnoses related to the feet, carpal tunnel syndrome, acid reflux, hemorrhoids, poor circulation, headaches, and jock itch. At his September 1990 separation examination, his head, neurologic system, upper extremities, feet, rectum/anus, vascular system, and skin were normal. On his Report of Medical History, he denied having any bone, joint, or other deformity; foot trouble; frequent indigestion; stomach trouble; rectal disease; frequent or severe headaches; and skin diseases. At the Veteran’s June 1986 enlistment examination, it was noted that he had a mole on the right side of his neck. His service treatment records are otherwise unremarkable for any complaints, treatment, or diagnoses related to moles. At his September 1990 separation examination, his skin was normal and denied having any skin diseases. Post service, regarding hemorrhoids, a July 2000 VA treatment record noted that the Veteran had hemorrhoids. He underwent hemorrhoid surgery in April 2008. Regarding acid reflux, an October 2010 VA treatment record indicated that the Veteran was prescribed a proton pump inhibitor, which is used to treat gastrointestinal issues such as acid reflux. A November 2011 private treatment record noted that he continued to have persistent reflux despite being on medication. Regarding poor circulation, a March 2006 VA treatment record noted that the Veteran had a venous stasis ulcer of the left ankle. In June 2006, he was prescribed compression stockings. Venous insufficiency was noted on his active problem list. Regarding headaches, a January 2002 VA treatment record indicated that the Veteran stated that he had no problems with headaches. In March 2010, he complained of headache, muscle spasms, and left shoulder pain. A December 2010 private psychotherapy record noted that he reported he was in a car wreck during service and went through the windshield. It was noted that he had problems with headaches, poor memory, and concentration. The Board notes that his service treatment records do not document such a motor vehicle accident and that an April 2015 VA treatment record indicated that he denied having a history of head injury. In November 2019, a private treatment record indicated he denied having frequent headaches. In October 2020, headaches were noted on his problem list. Regarding jock itch, a November 2010 private treatment record indicated that the Veteran complained of jock itch, which he stated he had from the military. He requested a letter from his physician stating that his condition was related to the military. The physician stated that it was not caused by the military and that everyone was exposed to fungus, but that some people are more susceptible to flares than others. Regarding carpal tunnel syndrome, a March 2011 record from a private psychologist, Dr. K.S., noted that the Veteran had a diagnosis of carpal tunnel disorder. An October 2015 VA treatment record indicated that he complained of bilateral wrist and hand pain, which increased with use and activity. He was issued carpal tunnel syndrome braces. Regarding a bilateral foot disability, a March 2016 VA treatment record noted that the Veteran reported that he had diabetes and was concerned about his feet. It was noted that he had flat feet and he was referred to prosthetics for a shoe consultation. Therapeutic shoes were issued in April 2016. The Board notes that the Veteran was not provided with VA examinations in conjunction with the claims for service connection. VA must provide a medical examination when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability; but (4) insufficient competent medical evidence on file for the Secretary to make a decision on the claim. See 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, however, the evidence does not indicate that the Veteran’s bilateral foot disability, carpal tunnel syndrome, acid reflux, hemorrhoids, poor circulation, headaches, jock itch, or moles may be associated with his service. See McLendon, 20 Vet. App. at 83; see also Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010). There were no complaints of any foot, wrist, acid reflux, hemorrhoid, poor circulation, headache, jock itch, or mole problems during service. At his separation examination, his head, neurologic system, feet, upper extremities, anus/rectum, vascular system, and skin were noted as normal. Furthermore, he denied having any foot trouble, joint problems, frequent indigestion/stomach problems, frequent or severe headaches, rectal disease, and skin diseases at separation and there is no medical evidence otherwise linking his current conditions to service. Accordingly, the Board finds that VA examinations for those issues are not warranted. In this case, the Board finds the most probative evidence weighs against the claims. The first complaints and objective evidence of the claimed disabilities occurred many years after service. The passage of time between discharge from active service and the medical documentation of a claimed disability is a factor that tends to weigh against a claim for service connection. Maxson, 230 F.3d at 1333. Furthermore, there is no medical evidence linking the Veteran’s claimed disabilities to his military service. The Board has also considered the lay evidence of record. The Veteran is competent to describe what he has personally observed or experienced. However, the ultimate questions of diagnoses and etiology in this case extend beyond an immediately observable cause-and-effect relationship and are beyond the competence of lay witnesses. Accordingly, the Board finds that the preponderance of the evidence is against the claims and entitlement to service connection for a bilateral foot disability, carpal tunnel syndrome, acid reflux, hemorrhoids, poor circulation, headaches, jock itch, and moles is not warranted. 38 U.S.C. § 5107(b); Gilbert, 1 Vet. App. at 49. REASONS FOR REMAND Service Connection – Left Shoulder The Veteran maintains that he injured his left shoulder playing football during service. He stated that he went to sick call and was given Motrin, and that it has bothered him throughout the years. A VA examination was conducted in August 2020. It was noted that the Veteran reported that he was diagnosed with bilateral degenerative arthritis of the shoulders in approximately 1987. It was also noted that he had bilateral shoulder strain status post left shoulder rotator cuff repair. However, the VA examiner did not provide an opinion regarding the etiology of the left shoulder disabilities. Therefore, a remand is necessary for a VA medical opinion.   Service Connection – Bilateral Knees The Veteran maintains that his bilateral knee disabilities were incurred in or are related to active service. During the April 2018 Board hearing, he stated that he twisted his left knee while wrestling with his buddy during service. He stated that he went to sick call, was given an Ace bandage, and was put on light duty for a week or two. He stated that he also had right knee pain during service and had surgery on his right knee shortly after he got out of the Navy. A VA examination was conducted in August 2020. It was noted that the Veteran reported that he was diagnosed with bilateral knee strain and degenerative arthritis in approximately 1987. The VA examiner, however, did not provide an opinion regarding the etiology of his knee disabilities. Therefore, a remand is necessary for a VA medical opinion. Service Connection – Left Ankle The Veteran maintains that his left ankle disability was incurred in or is related to active service. A VA examination was conducted in August 2020. It was noted that the Veteran reported that he was diagnosed with bilateral ankle degenerative arthritis and sprains in approximately 1987. The VA examiner, however, did not provide an opinion regarding the etiology of his left ankle disabilities. Therefore, a remand is necessary for a VA medical opinion. Service Connection – Asthma The Veteran maintains that his asthma began during service and/or is caused or aggravated by his service-connected PTSD. In July 2018, the Board remanded the claim to obtain a VA medical opinion. The Board directed the AOJ to obtain a VA medical opinion addressing whether any currently present asthma was caused or chronically worsened by his service-connected PTSD. In rendering the opinion, the VA examiner was requested to address a medical article submitted by the Veteran in February 2014. The article was a medical abstract entitled “A Twin Study of Post-Traumatic Stress Disorder Symptoms and Asthma” published in August 2007. A VA examination was conducted in August 2020. The VA examiner opined that the opined that it was less likely than not that asthma was caused or aggravated by PTSD. The examiner indicated asthma was a physiologic and/or anatomic condition while PTSD was a psychological condition. However, the examiner did not address the medical abstract that was submitted by the Veteran in February 2014. Therefore, to ensure compliance with the Board’s remand instructions, a remand is necessary for an additional VA medical opinion. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection – Chronic Fatigue Syndrome The Veteran maintains that his chronic fatigue syndrome is related to obstructive sleep apnea. In light of the decision above granting service connection for sleep apnea, the Board finds that a remand is necessary for a VA examination to address the nature and etiology of any currently present chronic fatigue syndrome. Service Connection – Sinus Disability, Chronic Bronchitis The Veteran’s service treatment records indicated that he was treated for an upper respiratory infection in July 1987 and May 1987. In September 1987, he reported having a dry nonproductive cough. Post service, an August 2000 VA treatment record indicated that the Veteran reported experiencing sinus drainage. In November 2003, he complained of sinus congestion and was diagnosed with sinusitis. It was noted that he was doing well on Zyrtec but would replace it with Claritin. In October 2010, it was noted that he had a past history of bronchitis. A November 2011 private treatment record indicated that the Veteran reported having chronic allergies and sinus problems. As the evidence indicates that the Veteran had respiratory problems during service and has had sinusitis and reported bronchitis since service, the Board finds that a remand for a VA examination and medical opinion is necessary. The matters are REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. 2. Then, return the case to the VA examiner who conducted the August 2020 examination for an addendum opinion regarding the nature and etiology of the Veteran’s left shoulder disabilities. The claims file must be made available to, and reviewed by the examiner. After a review of the evidence of record, to include consideration of any newly received records, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any current present left shoulder disability had its onset during the Veteran’s active service, or is otherwise etiologically related to such service. A rationale for all opinions expressed must be provided. 3. Then, return the case to the VA examiner who conducted the August 2020 examination for an addendum opinion regarding the nature and etiology of the Veteran’s bilateral knee disabilities. The claims file must be made available to, and reviewed by the examiner. After a review of the evidence of record, to include consideration of any newly received records, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any current present knee disability had its onset during the Veteran’s active service, or is otherwise etiologically related to such service. A rationale for all opinions expressed must be provided. 4. Then, return the case to the VA examiner who conducted the August 2020 examination for an addendum opinion regarding the nature and etiology of the Veteran’s left ankle disabilities. The claims file must be made available to, and reviewed by the examiner. After a review of the evidence of record, to include consideration of any newly received records, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any current present left ankle disability had its onset during the Veteran’s active service, or is otherwise etiologically related to such service. A rationale for all opinions expressed must be provided. 5. Then, return the case to the VA examiner who conducted the August 2020 examination for an addendum opinion regarding the nature and etiology of the Veteran’s asthma. The claims file must be made available to, and reviewed by the examiner. After a review of the evidence of record, to include consideration of any newly received records, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any current present asthma is caused or chronically worsened by the Veteran’s service-connected PTSD. In rendering this opinion, the examiner must address the medical article submitted by the Veteran in February 2014, entitled “A Twin Study of Post-Traumatic Stress Disorder Symptoms and Asthma” published in August 2007. A rationale for all opinions expressed must be provided. 6. Then, schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of his claimed chronic fatigue syndrome. Any indicated studies should be performed. Based on the examination results and a review of the record, the examiner should indicate whether the Veteran meets the criteria for a diagnosis of chronic fatigue syndrome. If so, examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that any currently present chronic fatigue syndrome was caused or is aggravated by the Veteran’s service-connected obstructive sleep apnea. A rationale for all opinions expressed must be provided. 7. Then, schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of his claimed sinus disability and chronic bronchitis. Any indicated studies should be performed. Based on the examination results and a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that any currently sinus disability and chronic bronchitis had its onset in or is etiologically related to active service, to include in-service treatment for an upper respiratory infection and reports of a dry nonproductive cough. A rationale for all opinions expressed must be provided. 8. Confirm that the VA examination reports and all opinions provided comport with this remand and undertake any other development found to be warranted. 9. Then, readjudicate the issues remaining on appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Mishalanie, 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.