Citation Nr: 21022135 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 17-46 974 DATE: April 14, 2021 ORDER Service connection for left shoulder acromioclavicular joint osteoarthritis is denied. Service connection for right shoulder impingement syndrome with acromioclavicular joint osteoarthritis is denied. Service connection for Dupuytren’s contracture with degenerative arthritis of the left thumb is granted. Service connection for Dupuytren’s contracture with degenerative arthritis of the right thumb is granted. Service connection for multiple joint pain is denied. Service connection for headaches is denied. Service connection for a low back disability is denied. Service connection for a cervical spine disability is denied. Service connection for bilateral hearing loss is granted. REMANDED Entitlement to service connection for a left knee disability. Entitlement to service connection for a right knee disability. FINDINGS OF FACT 1. The Veteran’s left shoulder acromioclavicular joint osteoarthritis is not related to service and did not manifest within one year of separation from service. 2. The Veteran’s right shoulder impingement syndrome with acromioclavicular joint osteoarthritis is not related to service and did not manifest within one year of separation from service. 3. The Veteran’s Dupuytren’s contracture with degenerative arthritis of the left thumb is related to service. 4. The Veteran’s Dupuytren’s contracture with degenerative arthritis of the right thumb is related to service. 5. The Veteran does not have a systemic disability causing multiple joint pain. 6. The Veteran’s headaches are not related to service or to environmental exposures in southwest Asia. 7. There was no in-service event, disease, or injury related to a low back disability. 8. There was no in-service event, disease, or injury related to a cervical spine disability. 9. Bilateral hearing loss is related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for left shoulder acromioclavicular joint osteoarthritis are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2020). 2. The criteria for service connection for right shoulder impingement syndrome with acromioclavicular joint osteoarthritis are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2020). 3. The criteria for service connection for Dupuytren’s contracture with degenerative arthritis of the left thumb are met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 4. The criteria for service connection for Dupuytren’s contracture with degenerative arthritis of the right thumb are met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 5. The criteria for service connection for multiple joint pain are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2020). 6. The criteria for service connection for headaches are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2020). 7. The criteria for service connection for a low back disability are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2020). 8. The criteria for service connection for a cervical spine disability are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.317 (2020). 9. The criteria for service connection for bilateral hearing loss are met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.385 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1981 to March 1994. This appeal is before the Board of Veterans’ Appeals (Board) from a July 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. In December 2019, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge via videoconference. A transcript is included in the claims file. In March 2020, the Board granted service connection for posttraumatic stress disorder (PTSD) and remanded the remaining issues on appeal with instruction to obtain relevant records from the Social Security Administration and to obtain a new medical opinion for bilateral hearing loss. The appropriate records were obtained, and the Veteran underwent a VA examination in August 2020. The Board is therefore satisfied that the instructions in its March 2020 remand have been satisfactorily complied with. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic diseases, including arthritis and organic diseases of the nervous system such as sensorineural hearing loss, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran’s service personnel records indicate that he is in receipt of a combat action ribbon. In the case of a veteran who engaged in combat with the enemy in a period of war, lay evidence of in-service incurrence or aggravation of a disease or injury shall be accepted if consistent with the circumstances, conditions, or hardships of such service, notwithstanding the lack of official record of such incurrence or aggravation. The incurrence or aggravation may be rebutted by clear and convincing evidence to the contrary. See 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d); Libertine v. Brown, 9 Vet. App. 521, 524 (1996); Collette v. Brown, 82 F.3d 389, 392-94 (Fed. Cir. 1996). The standard used to determine whether a veteran engaged in combat with the enemy is reasonable doubt, which is to be resolved in a veteran’s favor. See VAOPGCPREC 12-99. The provisions of 38 U.S.C. § 1154(b), however, can be used only to provide a factual basis upon which a determination could be made that a particular disease or injury was incurred or aggravated in service, not to link the claimed disorder etiologically to a current disorder. See Libertine, 9 Vet. App. at 522-23. The provisions of 38 U.S.C. § 1154(b) do not establish service connection for a combat veteran; it aids him by relaxing the adjudicative evidentiary requirements for determining what happened in service. Clyburn v. West, 12 Vet. App. 296, 303 (1999). Service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021. See 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Unlike service connection on a direct basis, the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 do not require competent medical nexus of a link between the qualifying chronic disability and military service. Service connection is presumed unless there is affirmative evidence to the contrary, where the criteria are met. See 38 C.F.R. § 3.317(c); Gutierrez v. Principi, 19 Vet. App. 1 (2004). The term “Persian Gulf Veteran” means a Veteran who, during the Persian Gulf War, served on active military, naval, or air service in the Southwest Asia theater of operations. The Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). The term “qualifying chronic disability” means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) functional gastrointestinal disorders (excluding structural gastrointestinal disorders). 38 C.F.R. § 3.317(a)(2)(i). A medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. See 38 C.F.R. § 3.317(a)(2). “Objective indications of chronic disability” include both “signs,” in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For the purposes of 38 C.F.R. § 3.317, disabilities that have existed for six months or more or that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 1. Entitlement to service connection for left shoulder acromioclavicular joint osteoarthritis 2. Entitlement to service connection for right shoulder impingement syndrome with acromioclavicular joint osteoarthritis The Veteran claims service connection for disabilities of the bilateral shoulders. Service treatment records do not reflect any symptoms of or treatment for a shoulder disability. No such abnormality was noted at the Veteran’s February 1994 separation examination, and in the accompanying report of medical history he explicitly denied having ever experienced a painful or trick shoulder. Private treatment records reflect that in November 2014 the Veteran reported pain in his shoulder, left worse than right. Ranges of motion were normal. X-rays showed mild degenerative changes of the right shoulder. VA treatment records reflect that in March 2015 the Veteran reported pain in all his joints. He reported x-ray evidence of right shoulder arthritis. He was diagnosed with osteoarthritis. The Veteran underwent a VA examination in August 2015. He reported that he first noticed pain in his right shoulder in around 1999. He was diagnosed with bilateral acromioclavicular joint osteoarthritis with right shoulder impingement syndrome. The examiner opined that the disabilities were less likely than not related to service in southwest Asia. This opinion was based on the rationale that his disabilities were diseases with clear and specific etiologies and diagnoses. The examiner explained that impingement in the dominant shoulder of a physical laborer is a common condition caused by repetitive trauma to the rotator cuff. Similarly, acromioclavicular arthrosis begins to appear in people over the age of 20, and the Veteran’s current arthritis was asymptomatic. The examiner explained that unless the Veteran had an acute injury to the shoulder during active military service or claims a repetitive use injury which was symptomatic while on active duty, no possible exposure in southwest Asia can account for his shoulder disabilities. Private treatment records reflect that from March 2016 to May 2016 the Veteran underwent physical therapy for right shoulder pain secondary to osteoarthritis with a long history of operating machinery over the years. In an April 2016 statement, the Veteran’s wife reported that he began having intermittent shoulder pain in 1995-96, with constant severe pain in his shoulders since 1999. VA treatment records reflect that in April 2016 the Veteran reported chronic shoulder pain, right worse than left. He reported that his right shoulder felt like he is always carrying a backpack and tired. Social Security Administration records reflect that in September 2016 the Veteran described his work history. He stated that he worked from November 1994 to August 2015 as a machinist. He reported that his job involved moving 50-pound pieces 10 feet utilizing bending, reaching, lifting, crouching, and twisting. He stated that the heaviest weight lifted was over 100 pounds, but one third to two thirds of the workday he lifted 50 pounds or more. He underwent an examination in November 2016, at which time he reported right shoulder pain since 1994. In a February 2017 letter, the Veteran’s private treating physician stated that he was being treated for chronic bilateral shoulder pain, which he reported started during his service period from 1981 through 1994. Private treatment records reflect that in February 2017 the Veteran reported bilateral shoulder pain that began in service. He was diagnosed with shoulder pain. X-rays showed osteoarthritis of the left acromioclavicular joint. Private treatment records from a different provider reflect that in March 2017 the Veteran reported left shoulder pain that began in 2008 with a gradual onset that grew progressively worse over time. He was diagnosed with left shoulder pain. An April 2017 MRI of the left shoulder showed tendinosis and possible low-grade partial tearing of the bicep tendon, mild tendinosis of the supraspinatus and infraspinatus tendons, moderate acromioclavicular joint degenerative change, and small glenohumeral joint effusion. In June 2017 he was diagnosed with left shoulder impingement. He continued treatment through March 2018. At his December 2019 hearing, the Veteran reported his belief that his joint disabilities were the result of wear and tear in service. He stated that he did not report his pain in service because he was trying to reenlist and because the Marines bred a culture of not complaining about pain. In a January 2020 letter, the Veteran’s private treating physician repeated that he was being treated for chronic bilateral shoulder pain, which he reported started during his service period from 1981 through 1994. The physician further opined that his bilateral shoulder degenerative changes were as likely as not caused by military service. No rationale for this opinion was provided. The Board finds that the evidence weighs against a finding that the Veteran’s shoulder disabilities are related to service or manifested within one year of separation from service. Service treatment records do not show any shoulder injuries or reports of pain, and upon separation he explicitly denied a history of shoulder pain. He now states that he did this because he was trying to reenlist and because the Marine Corps fosters a culture where one does not report pain. His contemporaneous reports on separation, however, are more credible, because of the inconsistent statements in his treatment records. He has variously stated that his shoulder pain began in service, in 1994, in 1999, and in 2008. Furthermore, while he expressed his belief that his disability was the result of wear and tear, he spent more than two decades working as a machinist and described the strenuous labor required by this work. The August 2015 VA examiner opined that the lack of in-service injury or symptoms renders his disabilities less likely than not related to service. While his private physician gave a contrary opinion in January 2020, that opinion was not supported by a rationale. Remand for an additional opinion is therefore not necessary; there is no purpose in asking a VA examiner to reconcile disagreement with a baseless opinion. For these reasons, the Board finds that the evidence weighs against a finding that the Veteran’s shoulder disabilities are related to service or manifested within one year of separation from service. Service connection is therefore denied. 3. Entitlement to service connection for Dupuytren’s contracture with degenerative arthritis of the left thumb 4. Entitlement to service connection for Dupuytren’s contracture with degenerative arthritis of the right thumb The Veteran claims service connection for bilateral thumb disabilities. Service treatment records do not reflect any symptoms of or treatment for any thumb disabilities. The only abnormality of the upper extremities noted at the Veteran’s February 1994 separation examination was inflammation of the extensor tendon. Private treatment records reflect that in November 2014 the Veteran reported joint pain at the base of his left thumb. Tenderness was present. X-rays showed prominent degenerative changes at the left first carpometacarpal joint with joint space narrowing. VA treatment records reflect that in March 2015 the Veteran reported pain in all his joints. He reported hand weakness and heaviness in his arms. He was diagnosed with osteoarthritis and muscle weakness. The Veteran underwent a VA examination in August 2015. He reported current symptoms of pain in his left wrist and hand. X-rays showed mild arthritis. He was diagnosed with mild bilateral osteoarthritis of the proximal interphalangeal and distal interphalangeal joints with early bilateral Dupuytren contracture, as well as mild arthritis of the base of the left thumb. The examiner opined that these disabilities were less likely than not related to service in Southwest Asia. This opinion was based on the rationale that the disabilities were diseases with clear and specific etiologies and diagnoses which were commonly encountered in men of the Veteran’s age who, like the Veteran, had a history of physical labor. In an April 2016 statement, the Veteran’s wife reported that since sometime after 1999 he had severe constant pain in his fingers. The Veteran underwent another VA examination in May 2016. He reported gradual onset of bilateral hand pain beginning in 2007. He was diagnosed with bilateral Dupuytren’s contracture and degenerative arthritis. The examiner stated that this was a disease with a clear and specific diagnosis that is not associated with exposure to environmental hazards while stationed in southwest Asia. The examiner explained that arthritis and Dupuytren’s contracture are common, age-, gender-, and occupation-related medical conditions. Social Security Administration records reflect that in September 2016 the Veteran described his work history. He stated that he worked from November 1994 to August 2015 as a machinist. He reported that his job involved moving 50-pound pieces 10 feet utilizing bending, reaching, lifting, crouching, and twisting. He stated that the heaviest weight lifted was over 100 pounds, but one third to two thirds of the workday he lifted 50 pounds or more. He underwent an examination in November 2016, at which time he reported hand pain since 1994. In a February 2017 letter, the Veteran’s private treating physician stated that he was being treated for chronic bilateral hand pain, which he reported started during his service period from 1981 through 1994. At his December 2019 hearing, the Veteran reported that he started having issues with his thumbs in service. He reported that most of his job was typing, writing, and sitting at a desk. He reported that he was feeling pain but not saying anything about it. He stated that he did not report this pain because he was trying to reenlist and because the Marines bred a culture of not complaining about pain. The Board finds that the evidence is at least in equipoise as to whether the Veteran’s thumb disabilities are related to service. While the VA examiners explained their opinions entirely in terms of exposure to environmental hazards in southwest Asia, the Veteran was noted to have inflammation of the extensor tendon at his February 1994 separation examination. There is no opinion on record directly addressing this finding. As such, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s thumb disabilities are related to service, and service connection is therefore granted. 5. Entitlement to service connection for multiple joint pain The Veteran claims service connection for multiple joint pains. Service treatment records do not reflect any symptoms of or treatment for a generalized joint disability. No such abnormality was noted at the Veteran’s February 1994 separation examination, and in the accompanying report of medical history he explicitly denied having ever experienced arthritis, rheumatism, or bursitis. VA treatment records reflect that in March 2015 the Veteran reported pain in all his joints. He reported x-ray evidence of right shoulder arthritis. He reported hand weakness and heaviness in his arms. He was diagnosed with osteoarthritis and muscle weakness. The Veteran underwent a VA examination in August 2015. He reported that in 1994, six months after separation from service, he noticed pain and a popping sensation in his right knee. In around 1999 he noticed pain in the right shoulder migrating slowly down his toes. Without being aware of it, he slowly gained 45 pounds. He went on a diet and began to notice pain in his wrists, particularly the left. His current main symptoms were in his right shoulder and left wrist, but other joints including elbows and knees could hurt. The examiner found no evidence of a generalized arthritic condition or diagnosis. Rather, the Veteran’s symptoms were explained as diagnosable conditions with clear etiologies in each respective joint. In an April 2016 statement, the Veteran’s wife reported that in 1995-96 he began to experience “phantom” pains. These pains would begin in his right shoulder and affect each joint for 2-3 days, taking a month to travel through his shoulders, elbows, wrist, fingers, hips, knees, and toes. She reported that in 2007 he was told by his physician that he appeared to have the beginning of some sort of joint disease. Private treatment records reflect that in August 2016 the Veteran reported that he wanted to apply for disability because he had pain from head to toe, nothing specific. He was not given a diagnosis. Social Security Administration records reflect that in September 2016 the Veteran described his work history. He stated that he worked from November 1994 to August 2015 as a machinist. He reported that his job involved moving 50-pound pieces 10 feet utilizing bending, reaching, lifting, crouching, and twisting. He stated that the heaviest weight lifted was over 100 pounds, but one third to two thirds of the workday he lifted 50 pounds or more. At his December 2019 hearing, the Veteran reported his belief that his joint disabilities were the result of wear and tear in service. He stated that he did not report his pain in service because he was trying to reenlist and because the Marines bred a culture of not complaining about pain. The Board finds that the evidence weighs against a finding of a current disability encompassing all the Veteran’s joints. Rather, the medical evidence indicates that the Veteran has been diagnosed with separate, discrete diagnoses in the different joints of his body. While he is competent to report pain all over his body, he does not have the expertise necessary to determine if his pain arises from one overarching disability or multiple discrete disabilities. He stated that his physicians had considered a systemic diagnosis, but he has not identified records of such a diagnosis for VA to obtain. The August 2015 VA examiner found no such disability, and there is no competent evidence in the record to contradict this finding. Where the evidence does not support a finding of current disability upon which to predicate a grant of service connection, there can be no valid claim for that benefit. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As such, the Board finds that the evidence weighs against a finding of a current disability and service connection must therefore be denied. 6. Entitlement to service connection for headaches The Veteran claims service connection for headaches. Service treatment records do not reflect any symptoms of or treatment for headaches. No such abnormality was noted at the Veteran’s February 1994 separation examination, and in the accompanying report of medical history he explicitly denied having ever experienced frequent or severe headaches. The Veteran underwent a VA examination in August 2015. He reported that his headaches began five years after separation from service. He was diagnosed with migraine headaches. The examiner opined that the disability was a diagnosable chronic multi-symptoms illness with a partially explained etiology. This opinion was based on the rationale that migraine headaches are common and usually begin under age 40. The Veteran began having them in his mid to late 30s. His symptoms met the criteria for migraine headaches without aura. The examiner further explained that no exposure in southwest Asia is a known trigger for either an individual headache or chronic migraine headaches. In an April 2016 statement, the Veteran’s wife reported that he began to get severe migraine headaches around 2006 to 2008. At his December 2019 hearing, the Veteran reported that his headaches began just after he returned from Saudi Arabia. He stated that he did not report this pain because he was trying to reenlist and because the Marines bred a culture of not complaining about pain. The Board finds that the evidence weighs against a finding that the Veteran’s headaches are related to service. Service treatment records do not show any chronic headaches, and upon separation he explicitly denied a history of frequent or severe headaches. He now states that he did this because he was trying to reenlist and because the Marine Corps fosters a culture where one does not report pain. His contemporaneous reports on separation, however, are more credible, because of the inconsistent statements in his treatment records. He has variously stated that his headaches began immediately after returning from Saudi Arabia, five years after separation, or sometime from 2006 to 2008. Furthermore, the August 2015 VA examiner opined that his headaches were a diagnosable disability unrelated to exposure to environmental hazards in southwest Asia. There is no competent evidence in the record to contradict this opinion. For these reasons, the Board finds that the evidence weighs against a finding that the Veteran’s headaches are related to service, and service connection is therefore denied. 7. Entitlement to service connection for a low back disability The Veteran claims service connection for a low back disability. Service treatment records do not reflect any symptoms of or treatment for a low back disability. No such abnormality was noted at the Veteran’s February 1994 separation examination, and in the accompanying report of medical history he explicitly denied having ever experienced recurrent back pain. Private treatment records reflect that from March 2016 to May 2016 the Veteran underwent physical therapy for lumbar pain with a long history of operating machinery over the years. In an April 2016 statement, the Veteran’s wife reported that since sometime after 1999 he had severe constant pain in his back. Social Security Administration records reflect that in September 2016 the Veteran described his work history. He stated that he worked from November 1994 to August 2015 as a machinist. He reported that his job involved moving 50-pound pieces 10 feet utilizing bending, reaching, lifting, crouching, and twisting. He stated that the heaviest weight lifted was over 100 pounds, but one third to two thirds of the workday he lifted 50 pounds or more. He underwent an examination in November 2016, at which time he reported low back pain since 1994. X-rays showed mild degenerative disease. In a February 2017 letter, the Veteran’s private treating physician stated that he was being treated for chronic low back pain, which he reported started during his service period from 1981 through 1994. Private treatment records reflect that in June 2017 the Veteran underwent an MRI after reporting low back pain and stiffness. The MRI showed mild degenerative spondylosis. At his December 2019 hearing, the Veteran reported that he experienced constant backaches at separation from service. He stated that he did not report this pain because he was trying to reenlist and because the Marines bred a culture of not complaining about pain. In a January 2020 letter, the Veteran’s private treating physician repeated that he was being treated for chronic low back pain, which he reported started during his service period from 1981 through 1994. The Board finds that the evidence weighs against a finding of an in-service event, disease, or injury that is related to a current low back disability. The Veteran states that his back pain began in service, but there is no record of such pain in his service treatment records, and at his February 1994 separation examination he explicitly denied having ever experienced back pain. He now states that he did this because he was trying to reenlist and because the Marine Corps fosters a culture where one does not report pain. Notably, he does not claim any specific incident in combat that was the origin of his pain. His contemporaneous reports on separation are more credible in light of his inconsistent statements regarding the onset date of his other claimed disabilities, discussed above. His private physician opined that his disability was related to service but did not provide a rationale. Moreover, the duty to assist does not require remand for an examination where the evidence does not establish an in-service event, disease, or injury. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). For these reasons, the Board finds that the evidence weighs against a finding of an in-service event, disease, or injury that is related to a current low back disability. Service connection is therefore denied. 8. Entitlement to service connection for a cervical spine disability The Veteran claims service connection for a cervical spine disability. Service treatment records do not reflect any symptoms of or treatment for a cervical spine disability. No such abnormality was noted at the Veteran’s February 1994 separation examination. In an April 2016 statement, the Veteran’s wife reported that he has had constant severe neck pain since 1999. Social Security Administration records reflect that in September 2016 the Veteran described his work history. He stated that he worked from November 1994 to August 2015 as a machinist. He reported that his job involved moving 50-pound pieces 10 feet utilizing bending, reaching, lifting, crouching, and twisting. He stated that the heaviest weight lifted was over 100 pounds, but one third to two thirds of the workday he lifted 50 pounds or more. In a February 2017 letter, the Veteran’s private treating physician stated that he was being treated for chronic neck pain, which he reported started during his service period from 1981 through 1994. Private treatment records reflect that in February 2017 the Veteran reported neck pain that began in service. He was diagnosed with neck pain that radiated down his left arm. X-rays showed considerable chronic degenerative discopathy. Private treatment records from another provider reflect that in March 2017 the Veteran was diagnosed with a cervical strain and cervicalgia. An April 2017 MRI showed severe canal narrowing, severe bilateral foraminal narrowing, and marrow edema related to stress-related changes versus degenerative facet arthropathy. In June 2017 he was diagnosed with cervicalgia with radiculopathy. He continued treatment through March 2018. At his December 2019 hearing, the Veteran reported his belief that his joint disabilities were the result of wear and tear in service. He stated that he did not report his pain in service because he was trying to reenlist and because the Marines bred a culture of not complaining about pain. In a January 2020 letter, the Veteran’s private treating physician repeated that he was being treated for chronic neck pain, which he reported started during his service period from 1981 through 1994. The physician further opined that his cervical spine degenerative changes were as likely as not caused by military service. No rationale for this opinion was provided. The Board finds that the evidence weighs against a finding of an in-service event, disease, or injury that is related to a current cervical spine disability. The Veteran states that his neck pain began in service, but there is no record of such pain in his service treatment records. Notably, he does not claim any specific incident in combat that was the origin of his pain. He now states that he did not report his pain because he was trying to reenlist and because the Marine Corps fosters a culture where one does not report pain. His contemporaneous reports on separation, however, are more credible in light of his inconsistent statements regarding the onset date of his other claimed disabilities, discussed above. His private physician opined that his disability was related to service but did not provide a rationale. Moreover, the duty to assist does not require remand for an examination where the evidence does not establish an in-service event, disease, or injury. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). For these reasons, the Board finds that the evidence weighs against a finding of an in-service event, disease, or injury that is related to a current cervical spine disability. Service connection is therefore denied. 9. Entitlement to service connection for bilateral hearing loss The Veteran claims service connection for bilateral hearing loss. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000 and 4000 Hertz is 40 decibels or greater; or when the thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385. Service treatment records do not reflect any treatment for hearing loss. At his September 1984 reenlistment examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 5 10 0 LEFT 10 10 10 10 15 Speech audiometry was not conducted. No hearing loss abnormality was noted. In March 1986, he underwent a reference audiogram prior to duty in a hazardous noise area. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 15 15 5 10 0 LEFT 15 15 10 15 15 Speech audiometry was not conducted. At his May 1987 reenlistment examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 5 10 5 LEFT 5 10 10 10 5 Speech audiometry was not conducted. No hearing loss abnormality was noted. At a September 1988 examination for drill instructor duty, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 15 5 15 10 LEFT 5 15 10 10 20 Speech audiometry was not conducted. No hearing loss abnormality was noted. At his November 1988 reenlistment examination, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 15 5 10 10 LEFT 0 10 10 10 20 Speech audiometry was not conducted. No hearing loss abnormality was noted. In a July 1990 audiogram, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 5 10 5 LEFT 10 10 15 10 25 Speech audiometry was not conducted. In a December 1993 audiogram, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 10 5 15 10 LEFT 5 5 20 15 25 Speech audiometry was not conducted. No additional testing was conducted two months later at his February 1994 separation examination. No hearing loss abnormality was noted, but in the accompanying report of medical history the Veteran reported a history of hearing loss without further elaboration. VA treatment records reflect that in March 2015 the Veteran reported bilateral hearing loss. In an April 2016 statement, the Veteran’s wife stated that his hearing had deteriorated. She reported that upon his return from Desert Storm, his hearing was much worse. She stated that he spoke in a very loud voice and asked people to repeat themselves. The Veteran underwent a VA examination in May 2016. He reported difficulty hearing, asking people to repeat themselves louder. He reported noise exposure in service while serving as a communications center officer listening to loud signals and noise through headsets. He also reported serving with an artillery unit, exposed to firing cannon and guns. Post-separation, he was exposed to noise working as a machinist until October 2015. He denied recreational noise exposure. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 40 45 40 50 65 LEFT 35 40 20 45 60 Speech audiometry revealed speech recognition ability of 96 percent in each ear. He was diagnosed with bilateral mixed hearing loss. The examiner opined that hearing loss was less likely than not related to service. This opinion was based on the rationale that there was no treatment for mixed hearing loss during service. Private treatment records reflect that in March 2017 the Veteran had his hearing tested in connection with his reports of tinnitus. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 30 40 No record 65 LEFT 35 35 35 No record 60 Speech audiometry was conducted but it is not clear whether the Maryland CNC test was used. He was diagnosed with hearing loss. No etiology was given. In May 2017 he underwent another audiogram. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 35 40 50 55 LEFT 35 40 35 40 60 Speech audiometry was not conducted. He was diagnosed with mild to moderate mixed bilateral hearing loss, mostly sensorineural. At his December 2019 hearing, the Veteran reported that his hearing loss problems began in service. He reported that his in-service work in communications required him to listen to headphones at high volume. He also reported that the computers were loud. In a January 2020 letter, the Veteran’s private treating physician opined that his bilateral hearing loss was as likely as not caused by military duty. No rationale for this opinion was provided. The Veteran underwent another VA examination in August 2020. He reported having to ask people to repeat themselves. Pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 20 40 50 65 LEFT 20 20 30 45 55 Speech audiometry revealed speech recognition ability of 100 percent in each ear. He was diagnosed with bilateral sensorineural hearing loss. The examiner was unable to determine the etiology of the Veteran’s hearing loss without resorting to speculation. The examiner explained that there was a significant change in hearing during service, but it was restricted to the very high frequencies. Most hearing levels were the same at the beginning and end of service. His degree of noise exposure during time in service is considered extremely high. Following service, he worked in a machine shop for many years, which is also a high-level noise environment. The examiner explained that without hearing testing performed in the years immediately following service, it was a matter of speculation as to whether hearing loss was due to service or civilian work. Notably, the examiner also opined that tinnitus was at least as likely as not related to service based on his unusually high level of in-service noise exposure. The Board finds that the evidence is at least in equipoise as to whether the Veteran’s hearing loss is related to service. He was exposed to noise at such a level in service that his hearing was frequently tested, and such tests showed fluctuation in his thresholds. Although the August 2020 VA examiner stated that an opinion could not be offered without resort to speculation, the explanation provided by the examiner essentially states that hearing loss was equally likely due to service noise or civilian noise. Such an explanation meets the equipoise standard. Furthermore, the examiner failed to explain why the Veteran’s tinnitus was at least as likely as not due to military noise, yet his hearing loss was not. For these reasons, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s hearing loss is related to service, and service connection is therefore granted. REASONS FOR REMAND 1. Entitlement to service connection for a left knee disability is remanded. 2. Entitlement to service connection for a right knee disability is remanded. The Veteran claims service connection for disabilities of the bilateral knees. Service treatment records reflect that in August 1989 the Veteran reported bilateral shin pain for five days. He reported that he ran a lot, and his physician believed this may be the cause. At a podiatry follow-up he reported that the pain was worse on the left. X-rays showed a normal left tibia and fibula. He was diagnosed with shin splint syndrome versus stress pain versus stress fracture. No such abnormality was noted at his February 1994 separation examination, and in the accompanying report of medical history he explicitly denied having ever experienced a trick or locked knee. At his August 2015 VA examinations for multiple joint pain and bilateral shoulder disabilities, the Veteran reported that he first noticed a pain and popping sensation in his right knee in 1994, six months after separation from service. Private treatment records reflect that from March 2016 to May 2016 the Veteran underwent physical therapy for knee pain secondary to osteoarthritis with a long history of operating machinery over the years. In an April 2016 statement, the Veteran’s wife reported that he had right knee pain and buckling since 1992. Since sometime after 1999 he had severe constant pain in his knees. The Veteran underwent a VA examination in May 2016. He reported gradual onset of left knee pain while in service. He stated that initially the pain was intermittent, mostly after running. In civilian life, he worked as a machinist, which required standing and twisting on the line, causing aggravation of the knee pain until it became constant. Left knee x-rays showed mild patellofemoral arthritis; right knee x-rays were normal. He was diagnosed with osteoarthritis and patellofemoral pain syndrome of the left knee. The examiner stated that this was a disease with a clear and specific diagnosis that is not associated with exposure to environmental hazards while stationed in southwest Asia. The examiner explained that osteoarthritis occurs when the protective cartilage on the ends of bones wears down over time causing pain with movement. Social Security Administration records reflect that in September 2016 the Veteran described his work history. He stated that he worked from November 1994 to August 2015 as a machinist. He reported that his job involved moving 50-pound pieces 10 feet utilizing bending, reaching, lifting, crouching, and twisting. He stated that the heaviest weight lifted was over 100 pounds, but one third to two thirds of the workday he lifted 50 pounds or more. He underwent an examination in November 2016, at which time he reported knee pain since 1994. X-rays showed mild degenerative disease in the left knee and moderate degenerative disease in the right knee. In a February 2017 letter, the Veteran’s private treating physician stated that he was being treated for chronic bilateral knee pain, which he reported started during his service period from 1981 through 1994. In a March 2017 statement, the Veteran reported that in 1989 he incurred tibia and fibula injuries requiring 10 days of no physical duty. At his December 2019 hearing, the Veteran reported his belief that his joint disabilities were the result of wear and tear in service. He stated that he did not report his pain in service because he was trying to reenlist and because the Marines bred a culture of not complaining about pain. The Board finds that remand is necessary to determine whether the Veteran’s knee disabilities are related to service. While the May 2016 VA examiner found that his left knee disability was less likely than not related to environmental exposures in southwest Asia, no opinion was provided as to the right knee at all or to both knees regarding his in-service shin splints. As such, remand is required to obtain a medical opinion. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any additional medical evidence that may have come into existence but has not been associated with the record. 2. Obtain an addendum opinion from a qualified VA examiner regarding the Veteran’s claimed knee disabilities. The claims file must be reviewed by the examiner. An in-person or virtual examination may be ordered if the examiner deems it necessary. The examiner should offer an opinion as to whether it is at least as likely as not (i.e. 50 percent probability or more) that (a) the Veteran’s right and left knee disabilities are related to his in-service shin splints and (b) the Veteran’s right knee disability is related to environmental exposure in southwest Asia. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. After completing the above, and any other development deemed necessary, readjudicate the appeal. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Gallagher, 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.