Citation Nr: 21025639 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 16-33 172 DATE: April 28, 2021 ORDER Service connection for right knee disability is denied. Service connection for left knee strain disability is denied. Service connection for headaches is denied. Service connection for onychomycosis and athlete’s foot (tinea pedis) (claimed as right foot condition and left foot condition) is denied. An initial disability rating of 10 percent, but no higher, for left eyebrow residual scar is granted. REMANDED Entitlement to service connection for an acquired psychiatric disorder. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran’s right knee disability began during active service or are otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that the Veteran’s left knee disability began during active service or are otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that the Veteran’s headaches began during active service or are otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that the Veteran’s onychomycosis and athlete’s foot (tinea pedis) began during active service or is otherwise related to an in-service injury or disease. 5. The Veteran’s left eyebrow residual scar from a sutured wound is manifested as a painful, healed, and stable scar, which is less than 144 square inches (929 sq. cm). CONCLUSIONS OF LAW 1. The criteria for service connection for right knee disability are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for left knee disability are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for headaches are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for onychomycosis and athlete’s foot (tinea pedis) (claimed as right foot condition and left foot condition) are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for an initial disability rating of 10 percent, but no higher, for left eyebrow residual scar are met. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.7, 4.114, Diagnostic Code 7804. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 2006 to October 2009. These matters come before the Board of Veterans’ Appeals (Board) on appeal from July 2015 and August 2015 rating decisions. In September 2019, the Veteran testified at a videoconference Board hearing before the undersigned, and a transcript is of record. In November 2019, the Board remanded these issues as well as entitlement to service connection for residuals of a left ankle fracture and entitlement to a compensable disability rating for pseudofolliculitis barbae for further development, and the case has been returned for appellate consideration. In a July 2020 rating decision, service connection was granted for left ankle fracture residuals, evaluated as 10 percent disabling effective November 17, 2013; and an increased disability rating of 10 percent for pseudofolliculitis barbae was granted effective July 21, 2020. As this represents a full grant of the benefits sought, these issues are no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (noting that a grant of service connection extinguishes appeals before the Board). The July 2020 rating decision noted that both issues were granted in full. Furthermore, the Veteran has not expressed disagreement with either the disability evaluations or effective dates assigned. See 38 U.S.C. § 7105(c); 38 C.F.R. §§ 3.104, 19.52 (formerly 20.302), 20.1103. In a July 2020 supplemental statement of the case, service connection was denied for the claims as noted above, so those issues remain on appeal. Also, the representative’s October 2020 Informal Hearing Presentation only addressed the issues discussed herein. The claimant bears the burden of presenting and supporting a claim for benefits. 38 U.S.C. § 5107(a); Fagan v. Shinseki, 573 F.3d 1282, 1286–88 (Fed. Cir. 2009). In making determinations, VA is responsible for ascertaining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the preponderance of the evidence is against the claim, in which case the claim is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Here, the Board reviewed all evidence in the claims file, with an emphasis on that which is relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380–81 (Fed. Cir. 2000) (holding that the Board must review the entire record but does not have to discuss each piece of evidence). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board’s analysis will focus specifically on what the evidence shows, or fails to show, as it relates to the Veteran’s claims. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). For certain enumerated chronic diseases, such as other organic diseases of the nervous system, which includes migraines, service connection may be granted based upon a presumption of incurrence in or aggravation by service despite the lack of evidence of such disease during service if diagnosed and manifested to a compensable degree within a prescribed period, generally one year, after separation from qualifying service. 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); see Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); see also Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013) (constraining § 3.303(b) to those chronic diseases listed in § 3.309(a)). Additionally, for those same enumerated chronic diseases service connection may be granted despite the lack of evidence of such disease during service if there is a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” 38 C.F.R. § 3.303(b), 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. There must be competent medical evidence unless the evidence relates to a condition as to which lay observation is competent to identify its existence. 38 C.F.R. § 3.307(b). 1. Entitlement to service connection for a right knee disability. 2. Entitlement to service connection for a left knee disability. The Veteran seeks service connection for disability of the right and left knees. The question for the Board, therefore, is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has right and left knee strain and changes on imaging and he reports having experienced bilateral knee pain during service, the preponderance of the evidence is against finding that the Veteran’s current right and left knee disabilities began during service or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. § 1110, 5107(b); 38 C.F.R. § 3.303(a), (d); Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). In July 2020, the Veteran was afforded a VA examination for knee and lower leg conditions, during which right and left knee strain was diagnosed. It was also opined that the changes seen on May 2018 X-rays should also be included in the diagnoses. The X-ray of the right knee revealed mild soft tissue edema; small osteophyte formation; and enthesophyte at the superior aspect of the patella. The X-ray of the left knee revealed mild soft tissue edema and small osteophyte formation. As the Veteran has a current diagnosis for right and left knee disabilities, the first Shedden element is met. The Veteran’s DD Form 214 shows that his military occupational specialty (MOS) was parachute rigger and that he was in receipt of the parachute rigger badge and parachute badge. The Veteran’s service treatment records are silent for any symptoms, complaints, diagnoses, or treatment of a knee condition. At the Veteran’s September 2019 hearing, he stated that he jumped about 25 times during parachute training. He endorsed that his knee pain was not attributable to any single event or injury in service. He stated that, in addition to the required running, his “knees are pretty shot.” He endorsed that aches in his knees during service came and went. He stated that, because he was on the deployment team, he did not seek medical treatment so he would not lose his place on the team. As the Veteran’s assertion of right and left knee pain during service is consistent with his MOS, the Board finds that the second Shedden element is met. December 2015 X-rays revealed a left knee that was within normal limits. VA medical records show that in January 2016, the Veteran was seen by primary care when he reported a history of left knee pain since 2008. He claimed onset “after landing wrong on a jump while on active duty.” He reported that, since then, he had moderate range of motion and took Advil as needed. It was noted that recent X-rays of the knee were normal. He denied swelling or stiffness but reported continued pain of 6-8/10. It was recorded that examination of the left knee was within normal limits without crepitus, swelling, or effusion. The Veteran was instructed on stretching exercises and was prescribed diclofenac 50 mg twice a day. Records show that in March 2016 the Veteran called VA for assistance with “continued pain in both knees.” VA medical records show that in January 2017 the Veteran was seen by primary care for complaint of left knee pain, the examination of which was the same as recorded the year before. Again, stretching exercises were recommended. He was prescribed Indocin and a left knee brace was ordered. Records show that, during a routine visit to primary care in May 2018, he reported worsening knee pain. It was noted that examinations of the right and left knees were normal, and X-rays of both knees were normal. He requested a knee brace stating that “falls” were related to “bilateral knees” giving out. He denied injury from falling. A right knee brace was prescribed. At the Veteran’s September 2019 hearing, he stated that, after service, when he worked moving furniture, although he could pick things up, his knees would weaken and he would not be able to carry the load. He stated that his knee pain affected his balance. He stated that, now, he was a truck driver, and he had knee pain at the end of the day when getting out of his truck. He stated that he stopped frequently to get out and stretch so his knees would not stiffen up. He stated that he bought knee braces that his VA doctor approved of. He stated that at the end of the day, he had to ice his knees. He endorsed that this pain started in service and continued since then. He stated that, based on X-rays, he had not been diagnosed with a knee condition. He stated that he had been advised that “it’s probably just normal wear and tear as far as just part of my job and what I did in the military, just working.” In July 2020, the Veteran was afforded a VA examination for knee and lower leg conditions, during which knee strain was diagnosed. It was recorded that the Veteran reported that it began in 2008. It was noted that there was no evidence that he sought treatment for recurring knee pain prior to 2014-2015. It was noted that he had undergone multiple X-rays, which were noted as normal. It was noted that he wore a knee brace. He denied flare-ups. He reported difficulty with bending, walking, and going up/down stairs. Range of motion testing was recorded as normal with objective evidence of pain on flexion. All other aspects of the physical examination were indicated as normal or negative. It was noted that the Veteran reported increased knee pain when attempting to move furniture. As to the Veteran’s right knee, it was opined that it was less likely than not that the current knee condition was incurred in or caused by military service. It was explained that there was no chronic diagnosis for the knee made as the objective examination was normal with subjective symptoms of pain only. It was stated that the Veteran had not been diagnosed with a knee condition during service, and he sought treatment in 2015, which was six years after service. It was opined that, as the Veteran has worked as a truck driver as well as moving furniture, this could contribute to knee pain. Based upon a records review, a different VA examiner stated that, in addition to the diagnosed right and left knee strain, the findings from the bilateral knee X-rays from May 2018 should also be added to the Veteran’s current bilateral knee condition. It was opined that the Veteran’s bilateral knee condition was at least as likely as not “caused by acute post service overuse and the natural aging process respectively.” It was stated that there was no nexus between the Veteran’s in-service duties, including parachute jumping, and his current bilateral knee condition. It was stated that “[p]ain is a nonspecific symptom which is not pathognomonic for the Veteran’s” diagnoses. It was stated that “[s]train is not the same as and neither does it cause or progress” to the diagnoses found on his May 2018 X-rays. It was noted that the Veteran’s current knee condition was not found during service, which would have been the case if his parachute duties had caused bilateral knee strain. It was also noted that there was no medical record of chronic ongoing knee pain post-service. It was opined that the greatest risk factor for the Veteran’s current bilateral knee strain and the findings on the May 2018 X-rays was acute post-service overuse and the natural aging process. As factfinder, the Board has the responsibility to determine the credibility and weight to be given to the evidence. See Washington v. Nicholson, 19 Vet. App. 362, 367-68 (2005). While the Veteran is entirely competent to report the nature of his symptoms of right and left knee conditions, he is not competent to proffer an opinion as to a diagnosis or etiology. See 38 C.F.R. § 3.159(a)(1)–(2) (defining competent medical evidence and competent lay evidence); Charles v. Principi, 16 Vet. App. 370 (2002) (finding the veteran competent to testify to symptomatology capable of lay observation); Layno v. Brown, 6 Vet. App. 465, 469–70 (1994) (noting that competent lay evidence requires facts perceived through the use of the five senses); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (stating that “lay persons are not competent to opine on medical etiology or render medical opinions.”). Such opinions require specific medical training and are beyond the competency of a lay person, and accordingly, the Board finds the medical findings more probative. See Jandreau v. Nicholson, 492 F.3d 1372, 1376–77 (Fed. Cir. 2007); see also 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995); Prejean v. West, 13 Vet. App. 444, 448–9 (2000). As to the etiology of the Veteran’s right and left knee pain, the medical opinions are consistent that it is due to overuse related to the nature of his work and aging. This was stated by both July 2020 VA examiners, and, during his hearing, the Veteran testified that he was told the same thing by care providers. As there is no diagnosis of arthritis based upon imaging, the provisions of 38 C.F.R. §§ 3.303(b), 3.307, and 3.309(a) do not apply here. Consequently, as the preponderance of the evidence is against finding a nexus between the Veteran’s current right and left knee conditions and service, the third Shedden element is not met, and the claims fail. Based upon the foregoing, as the preponderance of the evidence is against the claims, the benefit of the doubt rule does not apply, and the claim must be denied. See 38 U.S.C. §§ 501, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). 3. Entitlement to service connection for headaches. As stated in his November 2014 claim, the Veteran seeks service connection for “Migraine headache.” He contends that his headaches are the result of an in-service injury when he was hit over the left eyebrow by a piece of tossed wood, resulting in a laceration that required suturing. The question for the Board, therefore, is whether the Veteran has a current disability that began during service or is at least as likely as not related to service, including as a chronic disease that was noted as chronic in service or that manifested to a compensable degree in service or within the applicable presumptive period, or whether continuity of symptomatology has existed since service. The Board concludes that, while the Veteran experiences unspecified headaches, they are not migraine headaches, and as such are not a chronic disease under 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a). While the Veteran experiences headaches and was hit in the head during service, the preponderance of the evidence is against finding that the Veteran’s current headaches began during service or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. § 1110, 5107(b); 38 C.F.R. § 3.303(a), (d); Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). During a May 2015 VA examination for headaches, the examiner recorded that the Veteran experienced “unspecified headaches.” The Board notes that the Veteran, while entirely competent to report the nature of his symptoms of headache and their onset, is not competent to proffer an opinion as to a diagnosis of migraine or etiology. See 38 C.F.R. § 3.159(a)(1)–(2); Charles v. Principi, 16 Vet. App. 370 (2002); Layno v. Brown, 6 Vet. App. 465, 469–70 (1994); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Such opinions require specific medical training and are beyond the competency of a lay person, and accordingly, the Board finds the medical findings more probative. See Jandreau v. Nicholson, 492 F.3d 1372, 1376–77 (Fed. Cir. 2007); see also 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995); Prejean v. West, 13 Vet. App. 444, 448–9 (2000). As the probative evidence establishes that the Veteran experiences unspecified headaches, the first Shedden element is met. The Veteran’s service treatment records show that in February 2008 he was treated in the emergency room for a two-inch laceration over his left forehead that required suturing. The laceration was caused by a piece of wood that had been tossed. It was recorded that he denied losing consciousness and that he reported having a headache. When he was seen in March 2008 for suture removal, he reported that he felt there was “an ‘indentation in the bone’ above the eye.” It was recorded that he denied headache. It was noted that no orbital swelling was observed and no bony defect was palpable. As the probative evidence establishes that the Veteran suffered a head laceration during service, the second Shedden element is met on a direct basis. In May 2015, the Veteran was afforded a VA examination for headaches, during which it was indicated that he had not been diagnosed with a headache condition. The examiner recorded that the Veteran had unspecified headaches and that he did not report migraine symptoms such as visual disturbances (auras, sensitivity to light), sensitivity to sound, nausea, or vomiting. It was recorded that the Veteran gave a history of “migraines that began a few weeks after a head injury in February 2008.” It was indicated that he reported that he experienced headache pain over the left eyebrow lasting less than one day. It was noted that the functional impact was the need to stop and rest until the headaches resolve, which was anytime between 30 minutes to two hours. In May 2015, he was also afforded a VA examination for initial evaluation of residuals of traumatic brain injury (TBI), during which it was indicated that he had not had a TBI or residuals of TBI. It was indicated that he did not have any subjective symptoms. The examiner opined that it was less likely than not that the Veteran’s headaches, referred to as migraines, were proximately due to or the result of the Veteran’s in-service injury. It was explained that there were “[n]o service treatment records available that document treatment or care of migraines. A nexus has not been established.” VA medical records show that in December 2015, when the Veteran was establishing care with VA, it was recorded that he had a history of “migraines since hit in the head/face with a piece of wood while on active duty, has left sided headaches, sinus pain when breathing cold air.” He reported that when he breathed cold air into his left nostril it made the entire side of his left head hurt/ache. It was recorded that he had complaint of headaches ever since being hit in the head while in service. During a February 2017 mental health consultation, “‘small migraines’” were noted. During his September 2019 hearing, the Veteran stated that, because of recurrent migraines and headaches he was getting after his in-service head injury, he underwent follow up evaluation to determine whether there were any fractured facial bones. He endorsed that his headaches started a couple of weeks after the injury and continued throughout service. He stated that the headaches would come and go, mostly in the daytime when working in the shop where there was a lot of dust. He stated that he could not breathe well and got congested. He stated that, now, when it gets cold, he gets headaches. He stated that the headaches originate “all over the inside of the head” and radiate back to the left side. The Veteran reaffirmed that the headaches began in service after his head injury and have continued since then. He stated that he had not been professionally evaluated for his headaches and that he self-medicated to treat them. He stated that usually he covered his head to get light out of his eyes and would take a nap. He reiterated that it was an issue particularly when it was cold. In a May 2020 addendum medical opinion, a VA examiner opined that it was less likely than not that the Veteran’s headaches were incurred in or caused by an in-service injury, event, or illness. It was noted that the Veteran had a headache condition due to sinus pain that was acute only in 2007. It was stated that there was “no evidence of chronicity of care for headache condition after 2007 including after the 2008 laceration.” It was noted that during the at least four subsequent contacts with health care during service no complaint of headache was recorded. It was stated that the “veteran’s lay statements and testimony” were not supported by his active duty treatment records. It was noted that there were no post active duty records showing chronicity of care or diagnosis for a headache condition “despite veteran’s reported severity of symptoms in testimony and lay statements.” The examiner explained that the nature of the Veteran’s headaches as being due to a head injury was not consistent with medical literature. It was noted that no head injury/TBI has been diagnosed, and the Veteran denied loss of consciousness at the time of treatment for the head laceration. Quoting from a cited literature source, it was stated that posttraumatic headache was defined as headache developing within seven days after head trauma or after regaining consciousness following head trauma. It is regarded as chronic when it continues for more than two months after an injury. It was stated again that no chronic headache condition has been diagnosed and that a diagnosis of post-concussion headache was not warranted because “1) no headache condition exists and 2) evidence does not support the diagnosis of a post concussion headaches as parameters are not met.” As factfinder, the Board has the responsibility to determine the credibility and weight to be given to the evidence. See Washington v. Nicholson, 19 Vet. App. 362, 367-68 (2005). The Veteran contends very specifically that the headaches he experiences began in service after he sustained a laceration over his left eyebrow, which required stitches. Consequently, the Board must draw distinctions between the commonly used words “headache” and “head injury” and the medical terms of art or diagnoses “migraine” and “head injury.” It also must consider causes of headaches. The Veteran credibly reports that he experienced headaches in service as well as currently because only the Veteran knows this fact. Based upon the nature of the symptoms reported, however, medical practitioners can identify which of the many types of headaches a patient may be experiencing. Here, after in-person examination for both headaches and TBI, the May 2015 VA examiner diagnosed the Veteran’s headaches as “unspecified headaches.” He was not diagnosed with migraine headaches. Between separation from service and his registration with VA in December 2015, it does not appear that the Veteran had a healthcare provider. At VA, he reported that he had a history of migraines. As the Veteran was found medically not to have migraines in May 2015, the Veteran’s use of the term appears to have been colloquial and is not probative. Furthermore, his VA medical care providers did not find that further evaluation was warranted and no treatment for migraines or headaches was provided. Consequently, as the Veteran does not have a current diagnosis of migraines, service connection based upon the presumptions under 38 C.F.R. §§ 3.307 and 3.309(a) do not apply. Accordingly, the third Shedden element is not met on a presumptive basis and the claim fails. The Board turns its attention to service connection of the Veteran’s unspecified headaches on a direct basis. The Veteran’s service treatment records establish that he reported having a headache when he was treated at the emergency room for suturing of his head laceration in February 2008. When the sutures were removed, it was recorded that headache was denied. The Veteran has reported that he had a headache several weeks later that lasted less than a day. In May 2015, the Veteran was physically examined, and the VA examiner determined that the Veteran had not had a TBI or “head injury” as a medical term of art. It is not disputed that the Veteran was hit in the head by a piece of wood during service, but, from a medical point of view, it did not constitute a head injury. Furthermore, it was opined that the Veteran’s unspecified headaches were not related to the in-service incident. In the May 2020 addendum medical opinion, a VA examiner explained it more clearly that headaches that occur as a residual of a head injury are very specific in nature symptomatically, and the Veteran’s presentation did not fit those criteria. Therefore, the Board finds that the preponderance of the evidence is against finding that his current unspecified headaches are related to his claimed in-service incident. The Board notes that the Veteran served approximately an additional 20 months after his head laceration. He testified that during service he experienced headaches during the daytime when working in the shop, presumably due to dust. He stated that he could not breath well and got congested. The Board finds these reports credible but notes that the Veteran reports a different etiology than his head laceration and there is no medical evidence that the Veteran complained of or was treated for problems related to his worksite at any time during service. He testified that currently his headaches are triggered mostly by cold weather, which appears to be yet another different etiology of the Veteran’s unspecified headaches. While the Board is prohibited from exercising its own independent judgment to resolve medical questions, see Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991), the Board finds that the evidence of record does not indicate that the Veteran’s current headaches are associated with the headaches he experienced while in service or with another service-connected disability. Therefore, remand for further development is not warranted. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Consequently, the third Shedden element is not met on a direct basis, and the claim fails. Based upon the foregoing, as the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply, and the claim must be denied. See 38 U.S.C. §§ 501, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). 4. Entitlement to service connection for a skin condition of the feet. The Veteran seeks service connection for a skin condition of the feet, essentially contending that it is the result of wearing boots and wet socks during service. The question for the Board, therefore, is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran currently has onychomycosis and athletes foot (tinea pedis), and evidence shows that he was treated for dermatophytosis tinea corporis during service, the preponderance of the evidence is against finding that the Veteran’s current skin condition of the feet began during service or is otherwise related to an in-service injury, event, or disease. 38 U.S.C. § 1110, 5107(b); 38 C.F.R. § 3.303(a), (d); Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). In July 2020, the Veteran was afforded a VA examination, during which onychomycosis and athlete’s foot (tinea pedis) were diagnosed. As the Veteran has a current disability, the first Shedden element is met. The Veteran’s service treatment records show that in May 2007 he was treated for a rash with central clearing and scaly borders, annular and localized, on the right foot. It was noted that it was enlarging but not spreading rapidly. It was noted that it was “not chronic.” Dermatophytosis tinea corporis was diagnosed and miconazole cream was prescribed. As the Veteran was treated for a skin condition of a foot during service, the second Shedden element is met. In May 2015, the Veteran was afforded a VA examination for skin diseases, during which a diagnosis of tinea corporis was noted of unknown date. The Veteran reported a history of a fungal condition of the bilateral feet that began in April 2007 for which he was prescribed a cream, which did not help. He reported that the condition gradually worsened and that he currently used Tinactin. The examiner indicated that the use of medication was constant/near-constant. The examiner stated that the Veteran did not have any active skin condition on the feet currently. It was opined that the claimed condition was at least as likely as not incurred in or caused by an in-service illness. It was noted that his service treatment records showed that he had dermatophytosis tinea corporis, but since he did not have a current active skin condition, the question could not be answered further. VA records show that in January 2016 the Veteran had a dermatology consultation, during which he complained of an “itchy rash between toes.” It was noted that there was a “red scaling rash between all toes and on soles of feet.” Tinea pedis was diagnosed, and the Veteran was educated on proper foot care. Lotrimin cream was prescribed to be used every night. He was to return to the clinic as needed. In July 2016, the Veteran presented a photograph each of the top and bottom of his feet with an affixed statement: “feet messed up by wearing boots and wet socks.” During his September 2019 hearing, the Veteran testified that the skin condition on his feet that began in service continued after service until currently. He stated that, although it is better than it was in service, he still must put cream on it. He endorsed that he experienced flare-ups of the condition. In January 2020, the Veteran was afforded a VA examination, during which the examiner opined that the Veteran’s foot condition was less likely than not incurred in or caused by service. It was stated that the Veteran had onychomycosis and athlete’s foot (tinea pedis), which was not the same condition the Veteran was treated for in service. Furthermore, it was explained, only the right foot was involved during service while, during the current examination, both feet were involved. It was explained that, during service, the Veteran’s dermatophytosis was acute only. It was stated that there was no evidence of chronicity of care, and his symptoms were subjective only. As factfinder, the Board has the responsibility to determine the credibility and weight to be given to the evidence. See Washington v. Nicholson, 19 Vet. App. 362, 367-68 (2005). Here, while the Veteran is entirely competent to report his symptoms of an observable rash on his feet, he is not competent to proffer an opinion as to diagnosis or etiology of any specific skin condition. See 38 C.F.R. § 3.159(a)(1)–(2); Charles v. Principi, 16 Vet. App. 370 (2002); Layno v. Brown, 6 Vet. App. 465, 469–70 (1994); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Such opinions require specific medical training in dermatology and are beyond the competency of a lay person, and accordingly, the Board finds the medical findings more probative. See Jandreau v. Nicholson, 492 F.3d 1372, 1376–77 (Fed. Cir. 2007); see also 38 C.F.R. §§ 4.40, 4.45, 4.59 (2017); DeLuca v. Brown, 8 Vet. App. 202 (1995); Prejean v. West, 13 Vet. App. 444, 448–9 (2000). The evidence is not in dispute that the Veteran was treated for a skin lesion on his right foot during service and that, since at least 2016, he has experienced a recurring skin condition on both feet. The medical records show, however, that the condition in service was not the same condition the Veteran currently experiences. That being the case, the preponderance of the evidence is against finding a nexus between the Veteran’s current skin condition of the feet and service. Consequently, the third Shedden element is not met, and the claim fails. Based upon the foregoing, as the preponderance of the evidence is against the claim, the benefit of the doubt rule does not apply, and the claim must be denied. See 38 U.S.C. §§ 501, 5107(b); 38 C.F.R. §§ 3.102, 4.3, 4.7; see also Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). Increased Rating Disability ratings are assigned under a schedule for rating disabilities and based on a comparison of the veteran’s symptoms to the criteria in the rating schedule. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Disability evaluations are determined by assessing the extent to which a veteran’s service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in the ratings schedule. Individual disabilities are assigned separate Diagnostic Codes, and ratings are based on the average impairment of earning capacity. See 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2. If there is a question as to which evaluation should be applied to the veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The primary focus in a claim for increased rating is the present level of disability. Although the overall history of the veteran’s disability shall be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Additionally, a staged rating is warranted if the evidence demonstrates distinct periods of time in which a service-connected disability exhibited diverse symptoms meeting the criteria for different ratings throughout the course of the appeal. Fenderson v. West, 12 Vet. App, 119, 125-126 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Additional separate disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. 38 C.F.R. § 4.14; see Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); Lyles v. Shulkin, 29 Vet. App. 107 (2017) (holding that 38 C.F.R. § 4.14 prohibits paying compensation twice for the same symptoms or functional impairment). Disabilities due to scars are rated under Diagnostic Codes 7800 through 7805. Diagnostic Code 7800 pertains to burn scar(s) of the head, face, or neck; scar(s) of rhe head, face, or neck due to other causes; or other disfigurement of the head, face, or neck, and the criteria are based upon degrees of disfigurement. 38 C.F.R. § 4.118, Diagnostic Code 7800. Under Diagnostic Code 7804, for unstable or painful scar(s), a 10 percent disability rating is warranted when there are one or two scars that are unstable or painful; a 20 percent disability rating is warranted when there are three or four scars that are unstable or painful; and a 30 percent disability rating is warranted when there are five or more scars that are unstable or painful. Note (1) defines an unstable scar as one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that where one or more scars are both unstable and painful, 10 percent shall be added to the evaluation based on the total number of unstable or painful scars. Note (3) states that scars evaluated under diagnostic codes 7800, 7801, 7802, or 7805 may also receive an evaluation under 7804 when applicable. 38 C.F.R. § 4.118, Diagnostic Code 7804. The Board notes that VA amended the criteria for rating skin disabilities effective from August 13, 2018. Neither Diagnostic Code 7800 nor 7804 were changed by the August 13, 2018, amendments. 5. Entitlement to a compensable disability rating for left eyebrow residual scar. The Veteran essentially contends that his service-connected scar over his left eyebrow is more disabling than contemplated by the assigned disability rating. His scar is currently rated as noncompensable under 38 C.F.R. § 4.118, Diagnostic Code 7800. The question for the Board, therefore, is whether his disability picture more nearly approximates the criteria for a higher disability rating. Based upon a careful review of the probative evidence of record, the Board concludes that a disability rating of 10 percent, but no higher, for the Veteran’s left eyebrow residual scar is warranted as set forth by the criteria under 38 C.F.R. § 4.118, Diagnostic Code 7804. In July 2015, the Veteran was afforded a VA examination for initial evaluation of residuals of TBI, during which it was indicated that he had a scar over his left eyebrow. It was indicated that the scar was neither painful nor unstable, and it was recorded that it measured 4 cm by 0.3 cm. The Veteran reported that during service he was hit in the head by a block of wood that had been tossed. It was recorded that the laceration was treated with suturing. During a July 2015 VA examination for skin diseases, a color photograph of the scar was taken. The Veteran also presented in July 2016 a color photograph in which the scar over his left eyebrow was clearly visible. During the Veteran’s September 2019 hearing, he endorsed that the scar over his left eyebrow did not lose its covering or break open. However, he endorsed that with changes of colder weather it was painful. He stated that objects brushing against it, such as a hat, or anything hitting the scar made it painful. He stated that it was “really more sensitive in the cold weather” than in heat. He stated that mostly in the winter, with any kind of breeze over the scar or keeping a head covering on, the scar was tender and painful. He emphasized that the movement of air and its temperature, a breeze, was a factor in when the scar was painful. He stated that during the summer it was not as much of a problem. In July 2020, the Veteran was afforded a VA examination for scars, during which the history was recorded as a laceration over the left eyebrow after being hit by a piece of wood, and the coarse was “stable, nonpainful.” The examiner indicated that the scar was neither painful nor unstable (meaning with frequent loss of covering of skin over the scar). The scar was measured as 4.5 cm by 0.2 cm. It was indicated that there was not gross distortion or asymmetry of facial features or visible or palpable tissue loss. It was indicated that the Veteran’s scar did not impact his ability to work. As factfinder, the Board must determine the credibility and weight to be given to the evidence. Washington v. Nicholson, 19 Vet. App. 362, 367-68 (2005). The Board observes that there is no evidence of record showing that the Veteran’s scar is disfiguring per the characteristics set forth in the criteria, and the Veteran does not contend otherwise. Consequently, the Board finds a higher evaluation under Diagnostic Code 7800 is not warranted. The Veteran is competent, and the Board finds him credible, to report his experience of pain from his scar over the left eyebrow. See 38 C.F.R. § 3.159(a)(1)–(2); Charles v. Principi, 16 Vet. App. 370 (2002); Layno v. Brown, 6 Vet. App. 465, 469–70 (1994); Caluza v. Brown, 7 Vet. App. 498, 511 (1995). That being the case, the Board finds that the lay evidence establishes that the Veteran’s scar is painful. Objective evidence of pain is not required for evaluating a scar under Diagnostic Code 7804, and, with this in mind, the Board finds that it is most favorable to the Veteran to evaluate his scar over the left eyebrow under 38 C.F.R. § 4.118, Diagnostic Code 7804. As the Board’s decision to change the diagnostic code assists the Veteran in allowing him to attain a compensable rating, this change is in accordance with the law. See Butts v. Brown, 5 Vet. App. 532, 539 (1993) (change to diagnostic code is appropriate so long as not arbitrary, capricious, or an abuse of discretion); Read v. Shinseki, 651 F.3d 1296, 1301 (Fed. Cir. 2011) (change in diagnostic code does not violate protective statutes). The probative evidence establishes that the Veteran has a single scar that is painful but not unstable, which supports the assignment of a 10 percent disability rating under Diagnostic Code 7804. 38 C.F.R. § 4.118, Diagnostic Code 7804. The Board finds that a higher or separate disability rating under the other diagnostic codes is not supported. The Veteran’s scar is not deep and non-linear and is not associated with underlying soft tissue damage. Although it is superficial and not associated with underlying soft tissue damage, it does not cover an area or areas of 144 square inches (929 sq. cm) or greater. Therefore, Diagnostic Codes 7801 and 7802, both prior to and from August 13, 2018, do not apply. 38 C.F.R. § 4.118, Diagnostic Codes 7801, 7802. Finally, the evidence of record does not establish that there are any other disabling effect(s) not considered in the rating criteria provided under Diagnostic Codes 7800-04 as contemplated under both pre- and post-August 13, 2018, Diagnostic Code 7805 (Scars, other; and other effects of scars evaluated under diagnostic codes 7800, 7801, 7802, or 7804). 38 C.F.R. § 4.118, Diagnostic Code 7805. Accordingly, the Board finds that the assignment of a 10 percent disability rating, but no higher, for a painful left eyebrow residual scar is warranted. REASONS FOR REMAND Entitlement to service connection for an acquired psychiatric disorder. On his November 2014 application for compensation, the Veteran sought service connection for posttraumatic stress disorder (PTSD). In April 2015, notice was provided to the Veteran of the required evidence to substantiate his claim. He failed to return the VA Form 21-0781, Statement in Support of Claim for Service Connection for PTSD, as requested. In a July 2015 VA memorandum, a formal finding was made that a stressor could not be verified. The Veteran’s DD Form 214 shows that his MOS was parachute rigger and that he was in receipt of the parachute rigger badge and parachute badge. His military personnel records and service treatment records are silent for any mishaps related to his parachuting duties. During the Veteran’s December 2015 registration for care at VA, a depression screen was negative and a PTSD screen was positive. When he was seen by a primary care physician in January 2016, it was noted that there was no mental health condition requiring further intervention. The Veteran was next seen in January 2017, at which time he sought evaluation “for his anxiety.” A mental health triage note shows that he reported moods of being angry, anxious, depressed, and irritable. He reported that he had been experiencing depression and anxiety “for past 6-7 years and not getting better.” The Veteran was seen by a clinical psychologist later that day. It was noted: “Veteran endorsing distress at recollection of military training exercise when fellow airman’s parachute got caught on his foot in 2008.” He reported: “‘I literally almost died mid jump and so did she, we got tangled up.’” He also reported being shot at in his civilian life. Testing revealed positive scores for anxiety and depression. His score for trauma was suggestive of PTSD, and it was noted that he had both military and civilian life trauma. It was noted that his flow of speech was “slightly rapid, wanting to get through traumatic stressors quickly.” When the Veteran was seen at the beginning of February 2017 by the psychologist, the assigned differential diagnosis was PTSD, unspecified. The following week he underwent biopsychosocial assessment. He reported having had anger management issues in high school. He stated, “‘I know it’s anxiety, my hands shake, I start to sweat, depression is a daily battle,’” and he cited onset as “‘what happened in the aircraft, Nov 2008.’” He reported that he was part of a mass exit on a C-130 and that he and another person came out at the same time, crashing into each other on the bottom of the plane. He reported that after they released they crashed into each other again such that he had to use his reserve parachute. He stated, “‘I was scared, that was my last jump. I know I’m not in the right place mentally.’” The Veteran reported having been shot at prior to the military, which he stated was a daily occurrence where he lived. He denied any civilian trauma as an adult. Regarding concerns/life stress areas, the Veteran stated that his primary stress was “‘[b]eing a failure, not being able to take care of my son, not hav[ing] a career or to progress.’” He reported that cannabis used to be his “‘coping mechanism.’” The social worker summarized that the Veteran reported symptoms consistent with “a trauma-related stress [disorder] and depression secondary to a parachute accident while in the Army in 2008.” It was recorded that he reported “ongoing stress of looking for a new job, health issues, estrangement from his son, and wanting to be independent.” Diagnoses of other-specified trauma-and stressor-related disorder and persistent depressive disorder were assigned. When seen the next day by a mental health nurse practitioner, mood disorder and r/o PTSD were diagnosed. During his September 2019 hearing, the Veteran testified that he was on a jump mission that involved 64 people jumping from a C-130, which had a large exit door. He stated that essentially all 64 people jumped from the same door at the same time. He stated that another jumper’s parachute got caught on his foot, which did not allow his parachute to open. He stated that it took his parachute 15 seconds longer to open such that he was closer to the ground when he opened his reserve parachute. He stated that it made for a heavy impact. He stated that this occurred in November 2008 and that it was his last jump. He stated that he feared for his life and that it was the closest he had been to death. He stated that he could not control the outcome except to go by his training. The Veteran testified that he replayed the event in his head and had some nightmares that woke him up. He stated that he thought about it “a lot.” He stated that the dreams did not keep him from sleeping every night or living, but they did recur. In May 2020, the Veteran was afforded a VA examination for mental disorders, during which unspecified anxiety disorder and cannabis use disorder, moderate, were diagnosed. In terms of whether symptomatology could be differentiated, it was stated that the Veteran endorsed a lifelong history of cannabis use beginning prior to military service “as evidenced by Entrance Exam.” The Veteran reported, “‘[b]asically the anxiety I have comes from jumping out of planes, pretty much a near death experience, I pretty much almost lost my life and that is why I got out, I had a female soldier jump with me, we hit under the plane, I was stuck in her parachute, I was 250 ft off the ground and I was able to pull my reserve and that is what made me get out, that happened in Nov or Oct 2008.’” In a separate medical opinion, the examiner opined that the Veteran’s psychiatric condition was less likely than not incurred in or caused by the claimed in-service event, namely the parachute incident. It was explained that the Veteran endorsed a lifelong history of cannibis use beginning prior to military service as evidenced by his entrance examination. It was stated that, as for his anxiety, there was no documentation of the Veteran seeking mental health services until February 2017. It was stated that, “even at that appointment it is reported that his stress was more related to current events than experiences in the military,” and it was quoted, “‘Primary Stress: Being a failure, not being able to take care of my son, not having a career or to progress.’” Once VA provides an examination, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Here, the Board finds this medical opinion inadequate for essentially being conclusory. See El-Amin v. Shinseki, 27 Vet. App. 136, 139 (2013) (citing 38 C.F.R. § 4.2 and emphasizing that examination reports lacking sufficient detail must be returned); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (“It is the factually accurate, fully articulated, sound reasoning for the conclusion... that contributes probative value to a medical opinion.”); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). The examiner focused on the Veteran’s marijuana use rather than the full content of the evidence of record. The examiner failed to note that the Veteran was first flagged with a positive PTSD screen in December 2015. Rather than focusing on the purpose of why the Veteran sought mental health treatment in 2017 and the diagnoses assigned at that time, of the 17-page report of the February 2017 biopsychosocial assessment, the examiner chose a single statement, which was used out of context. Furthermore, the examiner failed to consider the Veteran’s statements, even during the instant examination. See Miller v. Wilkie, 32 Vet. App. 249 (2020) (explaining that a VA examination is inadequate if the examiner does not consider lay evidence). Additionally, the Board notes that the Veteran’s VA medical records show that on many occasions he was difficult to contact and that stable housing has been an issue for him. That being the case, it is unclear whether the Veteran was adequately informed as to how to establish entitlement to service connection for PTSD. Additionally, with record evidence of a diagnosis of PTSD subsequent to his November 2014 claim, VA has a renewed duty to assist the Veteran in substantiating his claim for entitlement to service connection for PTSD. 38 U.S.C. §§ 5100, 5102, 5103, 5103A; 38 C.F.R. § 3.159(b). On remand, development should be undertaken to verify the parachuting event in which the Veteran claims he was involved in either October or November 2008. The Veteran must be afforded a new VA examination for either PTSD or mental disorders, as appropriate, to determine the nature and etiology of his acquired psychiatric disorders, taking into account the record evidence and accepted medical principles. 38 C.F.R. § 3.159(c)(4). This matter is REMANDED for the following actions: 1. Send a letter to the Veteran documenting the general means by which a claimant may substantiate an in-service stressor in support of service connection for PTSD, consistent with the requirements of 38 C.F.R. § 3.304(f). Contact the Veteran and request further information regarding his claimed in-service stressor of a parachuting incident in October or November 2008, including identifying details such as the location, date, names of individuals involved, and unit of designation at the time. Based upon the provided information, take all appropriate action to corroborate any claimed stressor events. 2. After the above directive has been completed, regardless of whether the Veteran responds with relevant information, the Veteran should be afforded a VA examination to determine the nature and etiology of any current acquired psychiatric disorder, including PTSD, anxiety, and depression, that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify any psychiatric disorder that has been present during the appeal period or within close proximity thereto. If the examiner disagrees with a prior diagnosis in the record, the examiner should explain why such a diagnosis is not warranted. For each diagnosis identified other than PTSD, the examiner should discuss whether it is at least as likely as not (50 percent probability or greater) that the disorder manifested in service or is otherwise causally or etiologically related to the Veteran’s military service. Regarding PTSD, the agency of original jurisdiction should provide the examiner with a summary of the Veteran’s verified in-service stressors. The examiner must be instructed that only these events may be considered for the purpose of determining whether exposure to an in-service stressor has resulted in PTSD. The examiner should determine whether the diagnostic criteria to support the diagnosis of PTSD have been satisfied. If the PTSD diagnosis is deemed appropriate, the examiner should then comment upon the link between the current symptomatology and any in-service stressor. Note that the fact that a disability is not mentioned or diagnosed in treatment records cannot serve as the sole basis for a negative finding. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The examiner must address any conflicting medical evidence of record. 3. Readjudicate the claim. L. CHU Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Leanne M. Innet, Associate 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.