Citation Nr: 21026764 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 17-04 366 DATE: May 3, 2021 ORDER Entitlement to an initial disability evaluation in excess of 10 percent for right-knee disorder is denied. Entitlement to an initial disability evaluation in excess of 10 percent for left-knee disorder is denied. Entitlement to service connection for migraine headaches is denied. Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied. Entitlement to service connection for respiratory disorder, to include asthma, is denied. FINDINGS OF FACT 1. The objective medical evidence shows at no time during the appeal period did right-knee disorder more closely approximate flexion limited to less than 45 degrees or less; right-side ankylosis; right-knee subluxation, instability or ligament tears causing patellar instability; dislocation of semilunar cartilage with frequent episodes of "locking," pain and effusion into the joint; extension limited to more than 10 degrees; or malunion or nonunion of the tibia and fibula. 2. The objective medical evidence shows at no time during the appeal period did left-knee disorder more closely approximate flexion limited to less than 45 degrees or less; left-side ankylosis; left-knee subluxation, instability or ligament tears causing patellar instability; dislocation of semilunar cartilage with frequent episodes of "locking," pain and effusion into the joint; extension limited to more than 10 degrees; or malunion or nonunion of the tibia and fibula. 3. The objective medical evidence shows migraine headaches were not incurred in active service, are not caused by an event, injury, or illness during active service and did not manifest to a compensable degree within one year of separation from active service. 4. The objective medical evidence shows GERD was not incurred in active service and is not caused by an event, injury, or illness during active service. 5. The objective medical evidence shows respiratory disorder, to include asthma, was not incurred in active service and is not caused by an event, injury, or illness during active service. CONCLUSIONS OF LAW 1. The criteria for an initial disability evaluation in excess of 10 percent right-knee disorder have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a Diagnostic Codes 5260, 5256, 5257, 5258, 5259, 5261, 5262, 5263 (2020). 2. The criteria for an initial disability evaluation in excess of 10 percent left-knee disorder have not been met. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a Diagnostic Codes 5010-5260, 5256, 5257, 5258, 5259, 5261, 5262, 5263 (2020). 3. The criteria for service connection for migraine headaches have not been met, nor are they presumed to be. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2020). 4. The criteria for service connection for GERD have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). 5. The criteria for service connection for respiratory disorder, to include asthma, have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1979 to April 1991. In February 2020, the Veteran testified at a videoconference Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. These issues were remanded for development in May 2020, and have been returned to the Board. Increased Schedular Ratings Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (rating schedule), found in 38 C.F.R. Part 4. When a reasonable doubt arises regarding the degree of disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. 38 C.F.R. § 4.7 (2020). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Additionally, it is possible for a veteran to be awarded separate percentage evaluations for separate periods (staged ratings), based on the facts. See Fenderson v. West, 12 Vet. App. 119, 12627 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2020). In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Where an increase in the disability rating is at issue, the present level of the veteran's disability is the primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, the relevant overall temporal focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). The evaluation of the same disability under several diagnostic codes, known as "pyramiding," must be avoided; however, separate ratings may be assigned for distinct disabilities resulting from the same injury so long as the symptomatology for one condition is not duplicative of or overlapping with the symptomatology of the other condition. 38 C.F.R. § 4.14 (2019). When evaluating musculoskeletal disabilities, VA may, in addition to applying the schedular criteria, assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flare-ups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; see also DeLuca v. Brown, 8 Vet. App. 202, 204-07 (1995); Burton v. Shinseki, 25 Vet. App. 1, 5 (2011). Nonetheless, a disability rating higher than the minimum compensable rating is not assignable under any diagnostic code relating to range of motion where pain does not cause a compensable functional loss. Rather, the "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned. See Mitchell v. Shinseki, 25 Vet. App. 32, 37 (2011) (noting that while "pain may cause a functional loss, pain itself does not constitute a functional loss," and, is therefore, not grounds for entitlement to a higher disability rating). Additionally, the intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Thus, with or without degenerative arthritis, actually painful, unstable or malaligned joints, due to a healed injury, are recognized as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59; see also Burton v. Shinseki at 5 (holding that the provisions of 38 C.F.R. § 4.59 are not limited to disabilities involving arthritis). 1. Entitlement to an initial disability evaluation in excess of 10 percent for right-knee disorder. 2. Entitlement to an initial disability evaluation in excess of 10 percent for left-knee disorder. Right-knee disorder is rated under Diagnostic Code 5260, pertaining to limitation of motion, which provides a 10 percent rating when flexion is limited to 45 degrees. A 20 percent rating is warranted when flexion is limited to 30 degrees. A 30 percent rating will be assigned when flexion is limited to 15 degrees. 38 C.F.R. § 4.71a, Diagnostic Code 5260. Normal flexion is from 0 to 140 degrees. 38 C.F.R. § 4.71, Plate II. Left-knee disorder is rated under a hyphenated diagnostic code, 5010-5260. Generally, hyphenated diagnostic codes are used when an unlisted disability is at issue. See 38 C.F.R. § 4.27 (2020). In this case, the Agency of Original Jurisdiction (AOJ) assigned a hyphenated diagnostic code to recognize post-traumatic arthritis (Diagnostic Code 5010) as the Veteran's underlying diagnosis and limitation of left-knee motion (Diagnostic Code 5260) as the relevant rating criteria. See 38 C.F.R. § 4.20. Put more simply, the Veteran's left-knee joint has been diagnosed with arthritis, but it is rated under the code criteria for the resulting symptoms. Diagnostic Code 5010 has been recently revised, effective February 7, 2021, and addresses post-traumatic arthritis, which is to be rated as limitation of motion, dislocation, or other specified instability under the affected joint. If there are 2 or more joints affected, each rating shall be combined in accordance with § 4.25. Part 4 - Schedule for Rating Disabilities, § 4.71a Schedule of ratings musculoskeletal system, 85 Fed. Reg. 230, 76460 (November 30, 2020). A September 2013 rating decision granted service connection for right and left-knee disorders at 10 percent initial disability evaluation each, effective October 5, 2012, the date VA received the claims for service connection. The Board will consider evidence beginning in the period of one year prior to that date. A July 2013 VA examination for knee and lower-leg conditions shows diagnoses of right-knee patellofemoral syndrome and left-knee degenerative joint disease. The VA examiner noted the Veteran's report of having significant pain when it rains and at night, as well as when walking and running. Range of motion measurements show right-knee flexion at 115 degrees (140 degrees, normal) and extension at 0 degrees (normal), with no objective evidence of painful motion in either maneuver. The July 2013 VA examiner further found left-knee flexion at 110 degrees and extension at 0 degrees, again with no objective evidence of painful motion in either maneuver. She made no findings of pain, weakness, fatigability, or incoordination significantly limiting functional ability on repetitive-use testing. She noted the Veteran's report of flare-ups causing difficulty with prolonged walking and standing. Available imaging studies documented traumatic arthritis. The above range of motion measurements for each knee are well beyond any limitation of motion measurements set forth under Diagnostic Code 5260. However, in order to afford the Veteran every possible opportunity to attain the highest evaluation allowed under the regulations, the Board will also look to closely related or analogous diagnostic codes pertaining to the knee to determine if a higher evaluation might be available under those codes. Diagnostic Code 5256 provides rating between 30 and 60 percent for varying limitations of motion due to ankylosis (joint fusion/immobility due to trauma or surgery). However, the July 2013 examination report includes no findings of ankylosis. The recent revision of Diagnostic Code 5257, effective February 7, 2021, provides ratings beyond 10 percent for varying degrees of ligament tears causing instability, but the July 2013 VA examiner found all joint stability testing results to be normal, as well as finding no evidence or history of patellar subluxation/dislocation. Although she noted that x-ray evidence revealed a trace of irregular appearance on the anterior tibial plateau, raising the "possibility" of prior ligament or meniscus injury, she nonetheless found there were no meniscus (semilunar cartilage) conditions (Diagnostic Code 5258). Diagnostic Code 5261 offers higher ratings for limitation of motion in knee extension; however, the July 2013 VA examiner found normal extension in both knees. Diagnostic Code 5262, also recently revised, addresses impairments of the tibia and fibula and, although the Veteran reported an in-service left-proximal fibula fracture, the July 2013 VA examiner specifically found the Veteran did not have past or current tibial and/or fibular impairment. Diagnostic Codes 5259 and 5263 for meniscus removal and back-bending knee, respectively, do not offer ratings higher than 10 percent and, as the Veteran at this time is already rated at 10 percent in each knee, these diagnostic codes are not applicable, as an "extra" 10 percent added on for identical or similar symptoms is impermissible "pyramiding" of one diagnosis upon another. See 38 C.F.R. § 4.14. In an October 2016 VA examination for knee and lower-leg conditions, the VA examiner stated 1991 diagnoses of right and left-knee degenerative arthritis. He noted the Veteran's reports as stated above in the previous VA examination. The Veteran further reported functional loss of being unable to do much bending, he cannot walk as he used to and he has difficulty mounting stairs. Range of motion measurements show right-knee flexion at 5 to 85 degrees and extension at 85 to 5 degrees, with pain noted on examination causing functional loss in both maneuvers, affecting bending, stooping, and squatting and pain on weight-bearing. Left-knee flexion was at 5 to 90 degrees and extension at 90 to 5 degrees, with the same pain and functional loss noted above. The October 2016 VA examiner noted available imaging studies documented bilateral degenerative or traumatic arthritis. The above range of motion findings do not satisfy the criteria for any higher rating under Diagnostic Code 5260. Looking to analogous or related diagnostic codes, the October 2016 VA examiner found no right-side or left-side ankylosis (Diagnostic Code (DC) 5256), no subluxation or joint instability in either knee (DC 5257), no past or current tibial and/or fibular impairment (DC 5262), and no past or current meniscus (semilunar cartilage) conditions (DC 5258). As shown above, extension was at 85 to 5 degrees, far above the requirements under DC 5261 for a for higher ratings for varying degrees of limitation of movement. As directed by the Board in its May 2020 Remand, the Veteran was afforded another VA examination for knee and lower-leg conditions in August 2020, in which the VA examiner stated 2013 diagnoses of right-knee patellofemoral syndrome and left-knee degenerative joint disease. She noted the Veteran's reports as stated above in the previous examinations and with overall worsening symptoms. Range of motion measurements show right-knee flexion at 0 to 90 degrees and extension at 90 to 0 degrees, with pain during flexion noted on examination, but not resulting in or causing functional loss. Left-knee flexion and extension were the same, with pain during both flexion and extension noted on examination, but not resulting in or causing functional loss. She found in both knees pain, weakness, fatigability, or incoordination did not significantly limit functional ability on repetitive-use testing and the Veteran denied flare-ups. Available imaging studies documented left-knee degenerative or traumatic arthritis. The above range of motion findings do not satisfy the criteria for any higher rating under Diagnostic Code 5260. Looking to analogous or related diagnostic codes, the August 2020 VA examiner found no right-side or left-side ankylosis (Diagnostic Code (DC) 5256), no subluxation or joint instability in either knee (DC 5257), and no past or current tibial and/or fibular impairment (DC 5262), and no past or current meniscus (semilunar cartilage) conditions (DC 5258). As shown above, extension was at 90 to 0 degrees, once again far above the requirements under DC 5261 for higher ratings. The August 2020 VA examiner in 2 separate addenda in September and November 2020 addressed the findings in the July 2013 VA examination of "[f]unctional loss and additional limitation in [range of motion]," stating the functional loss and/or functional impairment is "[l]ess movement than normal," but the findings otherwise do not identify any other factors, such as pain on movement, weakened movement, excess fatigability, or incoordination. She also considered the July 2013 VA examiner's statements in the Section 19, "Remarks," as follows: "There are contributing factors of pain, weakness, fatigability, and/or incoordination and there is additional limitation of functional ability of the knee joint during flare-ups or repeated use over time. The additional limitation is described as difficulty with prolonged walking and standing due to knee pain. It is not feasible to estimate additional range of motion loss in degrees because of resorting to mere speculation." The Board in its May 2020 Remand asked the August 2020 VA examiner to resolve the above conflict in the July 2013 VA examiner's findings and remarks, to the extent possible. In her second addenda, the August 2020 VA examiner first noted that the July 2013 VA examiner found no objective evidence of painful motion for the right knee or left knee on examination. She further noted that the Veteran reported dull pain only and intermittent stiffness during the August 2020 examination, which also caused decreased range of motion for both knees, the range of motion for each knee being 90, but which did not elicit additional functional loss. She considered the lay evidence of the veteran, particularly his February 2020 testimony. Based upon her review of the current medical literature, the Veteran's medical records and the subjective and objective information gathered on her examination, the August 2020 VA examiner opined that it is more likely that the findings of functional loss and additional limitation of range of motion found in sections 6 and 19 of the July 2013 examination show a subjective finding of functional loss, as reported by the Veteran, rather than being the result of an objective finding on examination. The Board once again notes, based on the Veteran's own reports in the above examinations, symptoms of functional loss due to right and left-knee disorders were noted, as well as changes affecting normal working movements, which were sufficiently reviewed, included in the examination findings and considered in the assignment of the Veteran's current disability evaluation, but they have not presented a basis for a higher evaluation beyond the 10 percent rating for the effects of limitation of motion, due to the Veteran's reported pain on movement. See 38 C.F.R. §§ 4.40, 4.45, 4.59; See DeLuca v. Brown, 8 Vet. App. at 204-07; Mitchell v. Shinseki, 25 Vet. App. at 37; Burton v. Shinseki, 25 Vet. App. at 5. The Board has carefully considered the Veteran's February 2020 Board hearing testimony, as well as his reports to treatment providers and examiners as they appear throughout the record. The Board is well aware that lay persons are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran is competent to provide statements of symptoms which are observable to his senses and there is no reason to doubt his credibility. Nonetheless, the Veteran's lay evidence must in turn be weighed against other evidence, as all relevant evidence of varying kinds must be considered. For example, the Veteran contends in his testimony that his knees occasionally "lock up," whether when bent or straight. He added by way of example that when waking in the morning he has difficulty rising from his bed. Whether the foregoing symptom may suggest something like a "temporary" ankylosis, if such thing clinically could be found to exist, or perhaps is akin to something like a ligament tear or meniscus dysfunction is not the province of the Board to make such a determination. It does not have the expertise; it is not permitted to make its own unsubstantiated medical conclusions. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). The Board has looked to the findings of 3 VA examinations and 2 addenda opinions over the period from July 2013 through November 2020, as well as considering the rating criteria of Diagnostic Code 5260 and in total no less than 7 closely related or analogous diagnostic codes in an effort to provide the Veteran with any possible alternatives for evaluations at higher ratings. However, the record of examinations and treatment visits throughout the record did not produce findings of knee-joint immobility, fusion or joint instability or any of the relevant rating criteria under the diagnostic codes for higher evaluations. Without such findings, there is no basis on which the Board can assign higher ratings. The Board therefore assigns more probative value to the findings of the July 2013, October 2016, and August 2020 VA examiners. Their examinations and testing were conducted by medical professionals during in-person sessions with the Veteran, they thoroughly reviewed the Veteran's medical history and their findings, for the reasons stated above, exhibit sound clinical conclusions. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). For the foregoing reasons and based on the medical evidence of record, the Board finds the preponderance of the evidence is against initial disability evaluations in excess of 10 percent for right and left-knee disorders. Service Connection Generally, service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for a disability requires evidence of: (1) The existence of a current disability; (2) the existence of the disease or injury in service; and(3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). See also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Certain chronic diseases may be service connected on a presumptive basis if manifested to a compensable degree in a specified period of time post-service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. That period is usually one year. 38 C.F.R. § 3.307 (a)(3). 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. 38 C.F.R. § 3.303 (b). Under 38 C.F.R. § 3.303 (b), an alternative method of establishing an in-service disease or injury and a nexus for chronic diseases is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303 (b). 3. Entitlement to service connection for migraine headaches. The service treatment records (STRs) show an undated treatment note, but appearing in the records between October 1983 and January 1988, stating the Veteran had been in a jeep accident, hit his forehead, had developed a hematoma on his forehead, and also hurt his left-wrist and left-hand middle finger. However, no further treatment followed after that day. In a January 1985 periodic examination, the Veteran denied past or current frequent or severe headaches. In the March 1991 separation examination, the Veteran reported past or current frequent or severe headaches. The examiner noted the Veteran's further report of headaches for the prior 2 years. The post-active-service record shows in a July 1991 VA examination for disability evaluation, the VA examiner noted the Veteran's "history of 'migraine' headaches x 1yr, bitemporal 'pounding' headaches [with associated] blurred vision." However, he further found "normal neurologic findings." His diagnosis included a history of migraine headaches. In August 1991 the Veteran presented to VA with headache pain for the previous 3 to 4 days and reported a feeling of "stuffiness." The treatment provider assessed him with "[a]lteration in comfort[.] Patient tested for infection." He diagnosed, "Headache cold [symptoms]." On physical examination, the Veteran's pain was noted as exacerbated by percussion. Nonetheless, he was alert and oriented to time, place, and person and in no acute distress. He referred the Veteran to a medical doctor for evaluation for migraines, but there is no record of this. However, in a September 2001 non-active-duty "prescreening" examination, the Veteran denied past or current frequent or severe headaches. At VA in August 2003, the Veteran was prescribed medication for migraine headaches. When presenting to VA in September 2003 with headaches, the diagnostic impression of the ophthalmologist was the Veteran has myopic vision and headaches were possibly due to his blurry vision. In November 2003, the Veteran's headaches were noted as having been "worked up by neurology as uncomplicated migraines." They were characterized as temporal in location with 9/10 pain intensity, pulsatile, "with + photophobia + phonophobia, - nausea/vomiting no sensory loss no motor paralysis/aphasia reported. The [patient] tears when the headaches occur." An August 2004 VA neurology note shows the Veteran presented for headaches. The above symptoms were noted and the Veteran was assessed with uncomplicated migraine. In a February 2011 VA emergency department note, the treatment provider rendered a primary diagnosis for that encounter of migraine cluster headache. In September 2011, the Veteran presented at VA with "on-and off headaches for the prior 4 days, when he was developing a fever. In July 2013, the Veteran underwent a VA examination for headaches, which stated a 1989 diagnosis of migraine, including migraine variants (the Board in its review of the record has not found this diagnosis). The VA examiner noted the Veteran's report of the in-service motor vehicle accident and his subsequent diagnosis of migraine headaches. The July 2013 VA examiner opined that the Veteran's migraine headaches disorder was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. She explained that there were no in-service records confirming a complaint of headache or diagnosis of a headache disorder. A July 2016 VA primary care physician note shows the Veteran's headaches were assessed as stable, with the continuance of medication as needed. In May and June 2017, the Veteran presented to VA with a sudden onset of headaches, but it did not seem typical to the treatment provider, who found the etiology unclear and consulted with the neurology department. The neurology consult noted additional acute onset of diplopia. The original treatment provider noted it was most likely a microvascular 6th nerve palsy, with no evidence of a stroke. The Veteran has submitted a March 2020 private Disability Benefits Questionnaire (DBQ) for headaches, in which Dr. J.A.K. diagnosed migraine, including migraine variants. Dr. J.A.K. opined that, based on his review of medical records and medical history, the Veteran's migraines are at least as likely as not caused by his military service in the Gulf War. However, he provided no rationale for this opinion, making this opinion insufficient for a determination of service connection. The Board cannot simply accept an opinion without being informed of exactly how and on what basis a conclusion was reached, as such an opinion is no more than an assertion. In a September 2020 VA examination for headaches, the VA examiner stated a 2003 diagnosis of migraine, including migraine variants. She noted the Veteran's reports of the onset of headaches in or around 1992 and he was diagnosed with migraine in the 2000s and treated with sumatriptan and Imitrex with some improvement. She proceeded with various testing. She opined that headaches were less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. She explained in her rationale, "The veteran was diagnosed with uncomplicated migraine in 2003 (12 years since discharge). Therefore, a nexus has not been established." She further opined that it was less likely than not that immediate post-active-service findings in July and August 1991, made within one year of separation from active service, provide clinical evidence of the onset of chronic migraine headaches and that later records in fact show continuing chronic migraine headaches. After noting again the Veteran active duty dates of service, she explained, "No objective evidence found for complaints of headache/migraine during military dates or within 1 y[ear]. The veteran was [diagnosed] with uncomplicated migraine in 2003 (12 years since discharge). Therefore, a nexus has not been established." However, later in September 2020 she was requested to provide an addendum opinion to clarify her statement of no objective evidence found for complaints of headache/migraine during military dates, as the Veteran in fact reported headaches at the March 1991 examination for separation from active service, further reporting he had headaches for two years and the STRs document he was involved in an in-service Jeep accident in which he hit his forehead. The September 2020 VA examiner stated in her addendum the Veteran reported in September 2003 during treatment for migraines that he hit his head in a motor vehicle accident in the 1980s. She added, "There is an incomplete undated document (8/12) possibl[y] 2012? Found in c[-]file to substantiate [history of] generalized headache complaint without mention of motor vehicle accident (p1506/1526). No objective evidence was found for complaints of headache in 1991. Because of the 12 year gap, between 1991and 2003, it is less likely the headache incurred [in] or was from the [motor vehicle accident]." VA considers migraine headaches to fall within the category of "[o]ther organic diseases of the nervous system" and therefore a chronic disease which may be eligible for presumptive service connection under 38 C.F.R. § 3.309 (a). However, although the STRs show the Veteran's report of headaches in service, the STRs offer no medical evidence of diagnoses and treatment in service. Moreover, although in the July 1991 VA examination, conducted approximately 3 months after separation from active service, the VA examiner noted the Veteran's "history of 'migraine' headaches x 1yr, bitemporal 'pounding' headaches [with associated] blurred vision," this information was not found in the medical evidence, but conveyed through the Veteran's reports to the VA examiner, who otherwise found on examination "normal neurologic findings." The Board will note here that the Veteran's principal assertion in his Board hearing testimony is, although a nexus cannot be established, his headaches manifested within a year of separation from active service. He stated the 1991 treatment records at Brooklyn VA document this. The Board remanded this claim specifically for those records, as well as records from Manhattan and Bronx VA. The only records retrieved were approximately 420 pages from Bronx VA, with a statement there were no further records which have been archived. However, what does remain in the file from its original accumulation of medical records are 2 pages of treatment notes at Brooklyn VA from July through August 1991, showing, as stated above, the Veteran presented to VA in August 1991 with reports of headache pain for the prior 3-to-4 days and "stuffiness," with the treatment provider's assessment being "[a]lteration in comfort[.] Patient tested for infection" and his diagnosis of "[h]eadache cold [symptoms.]" Neither the Veteran's reports to the July 1991 VA examiner nor the August 1991 symptoms and diagnosis at Brooklyn VA indicating an association with a head cold satisfy the requirement of the manifestation of migraine headaches to a compensable degree (at least a 10 percent rating) within one year of separation from active service. Looking to the possibility of continuity of symptomatology establishing a nexus between an in-service injury or disease, such as headache pain, and migraine headaches as a current chronic disease, the Board first notes that the Veteran has alternatively reported to treatment providers and testified at the Board hearing that his headaches began after the in-service jeep accident in the mid-1980s. However, the STRs show no subsequent treatment for headaches and at the March 1991 separation examination, the Veteran reported that his headaches had begun 2 years prior, which would be sometime in 1989, fairly long after the accident, the undated treatment note of which appears in the file before a January 1988 note. Therefore, because headaches were never identified except by report in service, and putting aside the lack of medical evidence of any treatment for headaches at that time, it is otherwise impossible to establish continuity of symptomatology by relating the Veteran's reported symptoms to his current headache disorder of uncomplicated migraine diagnosed in August 2003, particularly after the "12 years since discharge," noted by the September 2020 VA examiner. Consequently, the presumption of service connection for headaches as a chronic disease is not available to the Veteran. The summary of the record does not show actual medical evidence of the identification, treatment, and diagnosis of headaches during active service and subsequent medical evidence therefore cannot not establish a relationship or nexus between the current disability and any injury or disease during active service. For the foregoing reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claim for service connection. 4. Entitlement to service connection for GERD. The STRs show in the March 1991 separation examination the Veteran's mouth and throat, as well as his abdomen and viscera, were normal. He denied past or current ear, nose and throat trouble and stomach, liver or intestinal trouble. The post-active-service record shows the Veteran presented at Brooklyn VA in February 2000 with symptoms identified by the treatment provider "reflux esophagitis." He further stated in his assessment, "believe gerd will get ugi [upper gastrointestinal] series and try lansoprazole 30 mg...." In the period of 2003 through 2004 of further visits to VA, the Veteran reported GERD as part of his medical history. The Veteran underwent a March 2018 VA examination for intestinal conditions, in which the VA examiner at the outset stated the Veteran has no past or current diagnosis of an intestinal condition. She noted Veteran's reports of having a long history of acid reflux, daily medication and having had a hernia repair after leaving the military, adding that the hernia was present the entire time he served. On examination, she found no signs or symptoms, no attacks or exacerbations and no otherwise pertinent findings. The March 2018 VA examiner opined that GERD was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. In her rationale, she explained the Veteran's disability pattern is a disease with a clear and specific etiology and diagnosis. GERD is caused by abnormal muscle function in the stomach which can disrupt flow. The abnormal structural problem such as a hiatal hernia is a biological problem which can weaken the lower esophageal sphincter muscles, leading to reflux disorder. "According to CPRS, the veteran was diagnosed with GERD in 2013. The CT [scan] of the abdomen that was complete[d] [in] June 2016, does not document any acute disease. The veteran also had a colonoscopy in 2010 that demonstrated a normal colon. There were no polyps, masses, or diverticuli [sic] present. The veteran is taking Pantoprazole daily. The STRs do not document a diagnosis of GERD or any treatments. It is less likely as not that the Veteran had a diagnosis of GERD while serving in the US military." In a September 2020 VA examination for esophageal conditions, the VA examiner stated a 2003 diagnosis of GERD. She noted the Veteran's reports of the onset of reflux (burning in chest) and food regurgitation since 1991, with worsening symptoms. She noted symptoms of pyrosis, reflux and regurgitation, but also noted that a June 2010 endoscopy revealed findings within normal limits. She opined that GERD was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. She explained that "the Veteran was first treated for GERD in 2003, 12 years after discharge from army active duty. The veteran[']s GERD is less likely incurred or caused by GERD during service. A nexus has not been established." The summary of the record does not show medical evidence of GERD during active service and subsequent medical evidence therefore cannot establish a relationship or nexus between the current disability and any injury or disease active during service. For these reasons and based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claim for service connection. 5. Entitlement to service connection for respiratory disorder, to include asthma. The STRs show in the March 1991 separation examination the Veteran's lungs, chest and sinuses were normal. The Veteran denied past or current asthma, shortness of breath and chronic cough, but reported sinusitis. The post-active-service record shows in a July 1991 VA examination a finding of vesicular breath sounds, with no rales or rhonchi. In the September 2001 non-active-duty "prescreening" examination, the Veteran denied past or current asthma, wheezing or inhaler use. In visits to VA between August 2003 and May 2017, the Veteran's respiratory findings on general examination showed normal, clear and unlabored breathing effort. For example, the February 2011 VA emergency department note, mentioned above, noted the Veteran's breath and lung sounds were bilaterally clear and respiration was even and unlabored. A March 2013 VA emergency department note shows the Veteran's respiratory effort was normal. August 2016 and January 2017 notes indicated on routine physical examination "non-labored breathing." A May 2017 VA note shows in its respiratory assessment a "[p]atent natural airway, no nasal flaring/grunting/stridor/cyanosis/cough noted. Respirations spontaneous/unlabored/symmetrical with regular rhythm & depth. Secretions clear/thin." In a June 2017 VA nurse's assessment note, the respiratory assessment showed "[a]irway patent; respirations spontaneous, unlabored, symmetrical, with regular rate, rhythm, and depth. Breath sounds clear." In a March 2020 private DBQ for respiratory conditions, Dr. J.A.K. diagnosed asthma. He opined that, based on his review of medical records and medical history, the Veteran's current diagnosis of asthma is at least as likely as not caused by his military service in the Gulf War. However, once again, he provided no explanation in the form of a rationale. For the same reasons stated in the previous section regarding headaches, Dr. J.A.K.'s is insufficient for purposes of determining service connection. In a September 2020 VA examination for respiratory conditions, the VA examiner at the outset stated the Veteran has no past or current diagnosis of respiratory condition. In noting the Veteran's report of having shortness of breath with wheezing in 1991, he further noted that "documentation states h[istory] of asthma since 2002." She concluded, "no objective evidence of asthma, no diagnosis warranted." The September 2020 VA examiner opined that respiratory disorder, to include asthma, was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. She explained in her rationale that "[n]o chronic diagnosis is made for respiratory disorder to include asthma. Objective exam is normal. Symptoms are subjective only. A Nexus has not been established." She further opined that respiratory disorder, to include asthma, was less likely than not caused by in-service exposures or other events or occurrences in service. She explained that all available records were reviewed, including Dr. J.A.K.'s March 2020 private respiratory DBQ, noting Dr. J.A.K.'s diagnosis of asthma was based on subjective findings only. All other diagnostic tests performed were within normal limits. "There is no objective evidence of asthma during the active military dates between 8/13/79 [and] 4/16/91. No chronic diagnosis is made for respiratory disorder to include asthma. Objective exam is normal. Symptoms are subjective only. A Nexus has not been established." In December 2020, the Veteran was afforded another VA examination for respiratory conditions, in which the VA examiner stated a July 2020 diagnosis of asthma. She noted the Veteran reports of intermittent bouts of shortness of breath beginning when he returned home from the Gulf War, use of daily medication and current nighttime asthma attacks requiring the use of an albuterol inhaler. She first opined that respiratory disorder, to include asthma, was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. She explained that the objective evidence shows asthma was diagnosed in July 2020. "NO earlier DX [diagnosis] is found in objective evidence. This was made more than 29 years post active duty. Therefore, no plausible direct service connection can be established. The nexus is NOT established." Addressing the question of does the Veteran have a diagnosis of shortness of breath/asthma/respiratory disorder that is at least as likely as not (50 percent or greater probability) incurred in or caused by (the) exposure to environmental hazards while stationed in the Persian Gulf during service, she next opined such that a disorder was less likely than not incurred in or caused by the claimed in-service injury, event or illness. She re-stated the above rationale. Additionally, as part of a December 2020 Gulf War general medical VA examination, the December 2020 VA examiner was requested to examine and evaluate the Veteran with his Southwest Asia service for any chronic disability pattern, as the Veteran has claimed a disability pattern related to respiratory disorder, to include asthma. The December 2020 VA examiner was to note that, if she determines the Veteran's disability pattern is either (1) an undiagnosed illness; or (2) a diagnosable but medically unexplained chronic multi symptom illness of unknown etiology, then no medical opinion or rationale is required, as these conditions are presumed to be caused by service in the Southwest Asia theater of operations. However, if, after examining the Veteran and reviewing the claims file, she determines that the Veteran's disability pattern is either (3) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (4) a disease with a clear and specific etiology and diagnosis, then she should provide a medical opinion, with supporting rational, as to whether it is at least as likely as not that the disability pattern or diagnosed disease is related to a specific exposure event experienced by the Veteran during service in Southwest Asia. The December 2020 VA examiner opined that respiratory disorder, to include asthma, was less likely than not related to such exposure. She explained in her rationale "[t]he four standard Gulf War disability patterns are not applicable for this case. There is no evidence of persistent/recurrent symptoms or concern of a diagnosis for the claimed condition [on which] the Veteran has claimed a disability pattern related to respiratory disorder, to include asthma." Based on the objective medical evidence, the Board finds the preponderance of the evidence is against the claim for service connection. For the above 3 service connection claims, the Board has considered the Veteran's February 2020 Board hearing testimony concerning his headaches, GERD and asthma, as well as his reports to treatment providers and examiners, as they appear throughout the record. As already stated above, the Veteran is competent to provide statements of symptoms which are observable to his senses and there is no reason to doubt his credibility. The Board has already addressed above the Veteran's Board hearing testimony of headaches manifesting within a year of separation from active service and further assertions of continuity of symptomatology. The Veteran has testified he experienced symptoms of GERD during active service, but he also testified he only self-medicated, but could not remember when he eventually sought treatment at VA. The medical evidence of record shows the earliest assessment of GERD was in February 2000, approximately 9 years after separation from active service, in which the treatment provider stated it was his belief ("believe gerd"). Regarding asthma, once again, the Veteran described current symptoms, but could not testify as to any in-service treatment for asthma and did not remember when he was diagnosed with it. The medical evidence shows a diagnosis of migraines no earlier than August 2003. None of the above medical or lay evidence establishes a nexus of reported in-service symptoms to post-active-service disorders. For these reasons, the Board assigns greater probative weight to the several VA examinations between July 2013 and September 2020. They were conducted by medical professionals during in-person examinations, they thoroughly reviewed the Veteran's medical history and their opinions, for the reasons stated above, exhibit sound clinical conclusions. See generally Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (noting that the central issue in assessing the adequacy of an opinion is whether the examiner was informed of the relevant facts in rendering a medical opinion). The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. As the preponderance of the evidence is against the claims, the doctrine is not applicable and the claims must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 4.3. MICHAEL D. LYON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. Franke, 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.