Citation Nr: 21027296 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 15-42 061 DATE: May 5, 2021 ORDER Entitlement to service connection for an ear disability manifested by hearing impairment and dizziness is denied. Entitlement to service connection for tinnitus is denied. Entitlement to service connection for a bilateral knee condition, to include as secondary to service-connected bilateral tibial stress fractures is denied. Entitlement to service connection for bilateral pes planus, to include as secondary to service-connected bilateral distal tibial stress fractures is denied. Entitlement to an evaluation in excess of 10 percent disabling for service-connected left distal tibial stress fracture is denied. Entitlement to an evaluation in excess of 10 percent disabling for service-connected right distal tibial stress fracture is denied. FINDINGS OF FACT 1. The preponderance of the evidence weighs against finding that the Veteran suffers an ear disability manifested by hearing impairment and dizziness that began during active service or is otherwise causally related to an in-service injury or disease. 2. The preponderance of the evidence weighs against finding that the Veteran suffers from tinnitus that began during active service or is otherwise causally related to an in-service injury or disease. 3. The Veteran's bilateral knee condition is not secondary to his service-connected bilateral distal tibial stress fractures or otherwise causally related to an in-service injury or disease. 4. The Veteran's bilateral pes planus is not secondary to his service-connected distal tibial stress fractures or otherwise causally related to an in-service injury or disease. 5. Throughout the appeal period, the Veteran's left distal tibial stress fracture has been manifested by no worse than a slight disability. 6. Throughout the appeal period, the Veteran's right distal tibial stress fracture has been manifested by no worse than a slight disability. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for an ear disability manifested by hearing impairment and dizziness have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303 (2018). 2. The criteria for establishing entitlement to service connection for tinnitus have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303 (2018). 3. The criteria for establishing entitlement to service connection for a bilateral knee condition, to include as secondary to service-connected bilateral distal tibial stress fractures have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.310 (2018). 4. The criteria for establishing entitlement to service connection for bilateral pes planus, to include as secondary to service-connected bilateral distal tibial stress fractures have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.310 (2018). 5. The criteria for establishing entitlement to an evaluation in excess of 10 percent disabling for service-connected left distal tibial stress fracture have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5299-5262 (2018). 6. The criteria for establishing entitlement to an evaluation in excess of 10 percent disabling for service-connected right distal tibial stress fracture have not been met. 38 U.S.C. §§ 1155, 5107 (2014); 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5299-5262 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had honorable active duty service with the United States Navy from July 1999 to November 1999. Pursuant to a May 2020 Board decision, this matter was remanded for additional development to include scheduling the Veteran for a new VA examination. As the requested development is now complete, this matter has been returned to the Board for appellate consideration. Duty to Assist and to Notify VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2018). Copies of compliant VCAA notices were located in the claim's file. VA's duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994). In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Thus, upon careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service connection, generally Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C. § 1110, 1131 (2014); 38 C.F.R. §§ 3.303 (a), 3.304 (2018). Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of 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 disease or injury incurred or aggravated during service (the medical 'nexus' requirement). See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a) (2018). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b) (2018). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and, (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (2014); 38 C.F.R. § 3.102 (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. Id. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant). Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue. 1. Entitlement to service connection for an ear disability manifested by hearing impairment and dizziness The Veteran asserts entitlement to service connection for an ear disability manifested by hearing impairment and dizziness. As outlined more fully below, the preponderance of the evidence is against his claim. Under the laws administered by VA, a certain threshold level of hearing impairment must be shown in order for hearing loss to be considered a disability. Impaired hearing will be considered a disability when the auditory threshold in any of the frequencies at 500, 1,000, 2,000, 3,000 and 4,000 Hertz is 40 decibels (dB) or greater; or when the auditory threshold for at least three of the frequencies at 500, 1,000, 2,000, 3,000 and 4,000 Hertz are 26 dB or greater; or when speech recognitions scores using the Maryland CNC (consonant nucleus consonant) test are less than 94 percent. 38 C.F.R. § 3.385 (2018). For purposes of determining whether service connection for bilateral hearing loss is warranted, the Board has thoroughly reviewed and analyzed all the evidence in the Veteran's claims file, placing an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no obligation to discuss, in detail, the extensive 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 claim. After a thorough review of the evidence, the Board finds that the evidence fails to show that the Veteran's ear disability manifested by hearing impairment and dizziness were caused by or otherwise related to active service. Service treatment records found no evidence of a physical abnormality on examination at enlistment in July 1999. A corresponding report of medical history denied any experience with hearing loss, ringing in the ears, a bilateral knee or ankle condition. An audiological evaluation, also dated July 1999, revealed normal findings. The examiner noted that the Veteran was not routinely exposed to hazardous noise. In August 1999, the Veteran was evaluated for pain and swelling of the legs over a 3-week period. Right ankle pain was also reported. A possible early stress fracture of the tibia was indicated. The Veteran was granted a profile for 7 days. A podiatry clinic record, dated September 1999, referenced increasing bilateral leg pain, worse on the right side than the left. Other symptoms included mild swelling and decreased ankle joint dorsiflexion. A diagnosis of distal medial tibial stress fractures was identified. The Veteran was provided a right ankle brace. Two months later, in October 1999, a follow-up examination was conducted. During the clinical examination, evidence of edema, erythema, and ecchymosis were observed. Mild to moderate tenderness to palpation impacted the bilateral distal tibia. Persistent symptoms were reported over an 8-week period. The Veteran described persistent pain with ambulation and an inability to run. A medical review board report indicated that the Veteran was referred to the Naval hospital for further evaluation. On physical examination, mild to moderate edema was observed about the bilateral distal tibias. An antalgic gait was listed as secondary to distal tibial pain. Severe tenderness to palpation at pinpoint was noted at the distal medial tibias. An increase in pain resulted from pressure or resistance of the lower tibias. Muscle strength was slightly reduced in the lower legs with good range of motion at the bilateral ankle joint, subtalar joint, and midtarsal joint. Radiological imaging and bone scans revealed a stress fracture at the distal medial aspect of the tibias. Minimal bone density changes were shown at the fractured area. The neurovascular status was within normal limits, bilaterally. Due to the Veteran's condition, his prognosis for continuing basic training and remaining in the military was deemed poor. As he was unable to fulfill the mandated physical fitness requirements of Boot Camp, the Medical Board determined that he was unfit to perform his military duties in a full duty capacity. Thereafter, the Veteran was separated from active service. Post-service treatment records show that the Veteran underwent an audiological evaluation in April 2014. The diagnostic findings revealed hearing within normal ranges in the left ear and mild high frequency sensorineural hearing loss in the right ear at 6000 Hertz (HZ) and 8000 Hz. During the clinical interview, he reported constant right-sided tinnitus and headaches. The Veteran denied any prior history of ear infections, ear surgery, or head trauma. No civilian noise exposure was reported. A physical examination revealed clear tympanic membranes, bilaterally. Acoustic reflexes were deemed consistent with hearing sensitivity. Speech recognition scores were described as "good." A primary care treatment record, dated March 2014, referenced bilateral ankle and knee pain. According to the Veteran, his symptoms dated back to active service. Therein, he sustained stress fractures to the bilateral ankles during boot camp following intensive physical training, which include running. A bone scan in 1999 confirmed bilateral tibial stress fractures. Other complaints of symptoms include progressive knee pain with age, and bilateral foot pain with prolonged walking or standing. An onset of symptoms began 4-5 years ago and impairs his ability to sleep. The Veteran endorsed use of a cane to ambulate. Bilateral knee braces provide some relief of his pain. The Veteran also reported an experience of tinnitus. In multiple lay statements, the Veteran reported an experience of hearing loss due to participation in firing drills during active service. He contends that the drills were performed without hearing protection. The Veteran complained of current symptoms including hearing impairment, dizziness with occasional loss of consciousness. He described the latter as his "body just shuts down." According to the Veteran, he suffers from persistent symptomatology dating back to active service. On the authorized audiological evaluation in December 2014 pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 15 15 20 15 LEFT 5 10 5 5 10 Pure tone threshold averages were 16 dB for the right ear and 8 dB for the left ear. Speech audiometry revealed a speech recognition ability of 92 percent in the right ear and of 100 percent in the left ear. A current diagnosis of high frequency sensorineural hearing loss beginning at 6000 Hz was observed in the right ear only. The Veteran described a functional impact as difficulty hearing in meetings to include a need to require others to repeat themselves. Due to tinnitus, he reports difficulty sleeping. Following the audiological evaluation, the examiner opined that the Veteran's right ear hearing loss is not etiologically related to active service. In support of the stated conclusion, the examiner noted that the Veteran's hearing was normal at enlistment and separation. No complaints of ear trouble or ringing in the ears was ever documented. In fact, the audiologist noted that the Veteran was not routinely exposed to hazardous noise. According to his DD-214, his official military occupation was listed as a Seamen's Apprentice. That role has been associated with a low probability of noise exposure. Moreover, there is no evidence of a significant threshold shift during active service. Thus, the examiner opined that it is less likely as not that the Veteran's current hearing loss and tinnitus were causally related to active service, to include as due to hazardous exposure therein. During a Board hearing in March 2020, the Veteran suggested a causal linkage between his hearing loss and tinnitus and participation in artillery fire drills during active duty service. He denied use of hearing protection and therefore, endured exposure to extremely loud noises. The Veteran identified current symptoms including hearing impairment, dizziness and occasional loss of consciousness. He endorsed ongoing symptomatology after separation. VA treatment records reflect some question as to the precise cause of these symptoms, though there was a suggestion of superior canal dehiscence that was not confirmed. Pursuant to a Board remand decision, dated May 2020, the Veteran was afforded a new VA examination. On the authorized audiological evaluation in October 2020 pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 25 20 35 20 LEFT 10 15 20 25 15 Pure tone threshold averages were 25 dB for the right ear and 18.75 dB for the left ear. Speech audiometry revealed speech recognition ability of 90 percent in the right ear and of 94 percent in the left ear. The Veteran's described functional loss as difficulty hearing in conversations with colleagues due to an inability to understand speech. Based on the audiological findings, a current diagnosis of sensorineural hearing loss was observed in the right ear only. Following the audiological examination, the examiner concluded that it was less likely than not that the Veteran's hearing loss is etiologically related to active service. In support of the stated conclusion, the examiner noted the absence of documented evidence of a threshold shift during active service. Moreover, the Veteran's military occupation was associated with a low probability of noise exposure. Similarly, the examiner opined that it is less likely than not that the Veteran's tinnitus is causally related to hazardous noise exposure. The opinion acknowledged the Veteran's lay assertions that he experiences a constant "siren" in the right ear, which began in August 1999. Specifically, he reported an onset of symptoms after striking the right side of his head on the cement due to a fall during physical training. While the examiner considered the Veteran's contentions, an etiological linkage could not be established due to an in-service head injury, as the record is silent for documented treatment for any such injury. On review of the record, the Board finds that service connection for an ear disability manifested by hearing impairment and dizziness is not warranted. Service connection is also not warranted for his complaints of tinnitus. In making all determinations, the Board has fully considered the competent medical evidence and all lay assertions of record. While the Board acknowledges the Veteran's subjective belief that his hearing impairment, experience of vertigo, and tinnitus are casually related to active service, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education, expertise, and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). There is no evidence that the Veteran possesses the required skills. Review of the record shows an initial report of symptoms on or about March 2014. Thereafter, audiological findings confirmed unilateral hearing loss and clear tympanic membranes, bilaterally. Acoustic reflexes were deemed consistent with hearing sensitivity. During multiple VA examinations, the Veteran's current symptoms and lay assertions were evaluated. At no time, have the diagnostic findings revealed a nexus between service-related hazardous noise exposure and the Veteran's complaints of symptoms. Even if the Board were to presume the veracity of the Veteran's complaints of hazardous noise exposure in-service, a causal linkage does not logically result from symptoms first reported more than a decade after separation. While the Board recognizes the Veteran's complaints of symptoms and his contention regarding their onset, the medical evidence does not support his contentions. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran's claims of entitlement to service connection for an ear disability manifested by hearing impairment and dizziness must be denied. Similarly, the Veteran's claim for service connection for tinnitus is also denied. 2. Entitlement to service connection for tinnitus The Board incorporates by reference, all arguments set forth in Section 1. 3. Entitlement to service connection for a bilateral knee condition, to include as secondary to service-connected bilateral distal tibial stress fractures The Veteran also contends that he is entitled to service connection for a bilateral knee condition, to include as secondary to service-connected bilateral distal tibial stress fractures. Service treatment records are silent for complaints of bilateral knee pain. Post-service treatment records confirm reports of bilateral knee pain. A pain clinic nursing note, dated March 2014, referenced bilateral ankle and knee pain described as a 7 on a 10-point scale. Pain was described as aching. The Veteran endorsed use of Aleve to treat pain. In April 2015, a current diagnosis of left knee synovitis was identified. Two months later, in June 2015, magnetic resonance imaging (MRI) of the left knee was unremarkable. On the same date, mild focal medial femoral chondromalacia was observed as to the right knee only. During a VA examination to assess the current severity of the Veteran's service-connected bilateral tibial fractures in February 2014, the range of motion of his bilateral knees was impaired. On subsequent examination in June 2014, range of motion testing of the bilateral knees revealed normal findings. However, the examiner failed to comment or specifically address the Veteran's longstanding history of physical therapy for bilateral knee impairments, including range of motion deficits. Instead, only a brief note acknowledged reports of knee pain and suggested it was unrelated to his service-connected bilateral tibial fractures. No rationale was provided in support of the conclusion. On examination in September 2015, A VA examiner opined that it is at least as likely as not (50 percent probability or greater) that the Veteran's bilateral knee condition is proximately due to or the result of his service-connected bilateral distal tibia stress fractures. In support of the stated findings, the examiner noted that stress fractures are a component of a shin splint condition. However, in spite of the Veteran's complaints of ongoing symptoms, X-ray films failed to document any evidence of his previous stress fractures in February 2014. Moreover, shin splints are often referred to as medial tibial stress syndrome (MTSS). Common symptoms include tenderness described as more diffuse with discrete palpable lesions. Palpable lesions are usually present when there is a stress fracture. "MTSS" is most often considered to be the result of overuse as seen in repetitive motion activities such as running or repetitive walking. In June 2016, the VA examiner identified two current diagnoses, bilateral shin splints and patellofemoral pain syndrome. In-service, a bone scan revealed bilateral distal tibial stress fractures. Current symptoms include ankle, toe, and bilateral knee pain. The Veteran also reported a history of gout. Range of motion testing revealed normal findings, bilaterally. Localized tenderness and pain were observed with flexion at the distal medial aspect of the tibia (at the muscular insertion). Additional factors contributing to the Veteran's disability included disturbance of locomotion, and interference with standing. Muscle strength and joint stability testing revealed normal findings. There was no evidence of muscle atrophy, crepitus, or ankylosis. A functional impairment was described as a limited ability to walk or stand for prolonged periods. The examiner found no evidence to support a change in diagnosis regarding the Veteran's service-connected bilateral lower leg fractures as the distal medial aspect of tibias. The new diagnosis of bilateral patellofemoral syndrome was deemed unrelated to his service-connected condition. No specific rationale was identified. One year later, in September 2016, VA physical therapy and rehabilitative treatment records documented pain with decreased range of motion in the bilateral knees, ankles, and feet, as well as diminished muscle strength, guarding, and functional impairments. The treating therapist related the Veteran's symptoms to basic training and his in-service diagnosis of distal medial tibial fractures. No basis for the opinion or supportive diagnostic findings were identified. Pursuant to the May 2020 Board decision, the Veteran's claim was remanded to resolve the inconsistencies in prior VA examinations, as well as the inadequate etiological opinion provided in the September 2016 VA examination. On examination in September 2020, current diagnoses included patellofemoral pain syndrome of the left knee, chondromalacia of the patella right knee, and bilateral distal tibial stress fractures. During the clinical interview, the Veteran reported pain in both knee joints dating back to basic training. Therein, he endorsed participation in strenuous running and physical drills. Progressive symptoms were reported since separation. Current symptoms include constant pain with worsening symptoms in the right knee. Pain was described as sharp and increasing due to prolonged standing, walking, kneeling, and squatting. Other symptoms include cracking and popping in both knees with weakness and fatigue. To treat pain, the Veteran endorsed use of a right ankle brace, steroid injections and Aleve. Physical therapy treatments provided minimal symptom improvement. To aid with ambulation, the Veteran reported regular use of a cane. Flare-ups of pain occur daily depending on level of activity and cause functional loss. Flare-ups were described as increased pain with prolonged walking, standing, kneeling, and squatting. Range of motion of the right knee revealed flexion and extension limited to 30 degrees. Range of motion does not contribute to functional loss. Pain was observed with flexion and extension. Localized tenderness or pain to palpation was noted at the lateral and posterior knee under the patella. Pain was described as severe and was attributed to chondromalacia. Objective evidence of pain was observed with weight bearing. There was no evidence of crepitus. Range of motion of the left knee revealed flexion and extension limited to 50 degrees. Range of motion does not contribute to functional loss. Pain was observed with flexion. Localized tenderness or pain to palpation was described as moderate. A relationship to his patellofemoral pain syndrome was indicated. Objective evidence of pain was observed with weight bearing. There was no evidence of crepitus. No additional loss of function or range of motion was observed with repetitive use testing, bilaterally. In the right knee, pain and fatigue caused functional loss with repetitive use over time. Specifically, an additional loss of flexion and extension of 10 degrees was noted. As to the left knee; pain, fatigue, and weakness caused functional loss of function with repetitive use over time. It resulted in an additional loss of flexion and extension of 10 degrees. No additional factors were listed as contributing to the Veteran's disability. Muscle strength testing was slightly reduced, bilaterally. There was no evidence of muscle atrophy or ankylosis. Joint stability testing revealed normal findings, bilaterally. Additional conditions included a prior history of stress fracture of the bilateral ankles, which impacts range of motion. Specifically, the Veteran's current symptoms were described as residual pain and tenderness at bilateral lower leg just above the ankle, to include with weight bearing and palpation. No current fracture of either tibia as was observed on x-ray films obtained in April 2006. Diagnostic testing failed to show any evidence of arthritis. A bone scan in May 2006 revealed mild increased uptake along the lateral aspects of both tibial shafts. This was deemed suggestive of shin splints. The remainder of the bone scan was negative. An MRI of the bilateral knees revealed pain, mild femoral chondromalacia on the right, normal imaging on left in June 2015. There was also no evidence of a meniscal condition. Use of assistive devices included a right knee brace due to constant pain related to chondromalacia. A functional impact was described as a limited ability to run, knee, crawl, or engage in prolonged walking or standing, or participate in high impact activities. As to the Correia factors, objective evidence of pain with non-weight bearing of passive motion was observed, bilaterally. Passive range of motion testing mirrored active motion findings. Following the clinical evaluation, the examiner noted additional diagnoses including patella femoral pain syndrome of left knee and chondromalacia of right patella. These conditions were deemed separate and independent from the Veteran's service-connected left and right distal tibial stress fractures. Considering the forgoing, the Board finds that service connection is not warranted for the Veteran's bilateral knee condition, to include as secondary to service-connected bilateral distal tibial stress fractures. In making all determinations, the Board has fully considered all lay assertions and medical evidence of record. Generally, the Veteran is deemed competent to report on his current symptoms and their onset. However, the record is silent for evidence showing that he possesses the specialized skills and expertise necessary to render complex medical opinions or opine as nature and etiology of his current symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377. Further, mere conclusory or generalized lay assertions that an in- service event or illness caused a current disability are insufficient to establish nexus in the absence of competent medical evidence. Waters v. Shinseki, 601 F.3d 1274, 1278. In this case, the medical evidence reveals that the Veteran has a current diagnosis of patella femoral pain syndrome of the left knee and chondromalacia of the right patella. Service treatment records are silent for any complaints of bilateral knee pain or any related diagnosis. Post-service treatment records show complaints of bilateral knee pain beginning on or about March 2014. A physical therapy treatment record suggested a correlation between the Veteran's lower extremity conditions and his service-connected bilateral tibia stress fractures. In multiple VA examinations, the Veteran's complaints of bilateral knee pain, limited motion, and difficulty with prolonged walking and standing were fully evaluated. However, at no time has his bilateral knee conditions been etiologically related to his service-connected tibial stress fractures. Moreover, the Veteran's bilateral knee conditions were deemed separate and independent from his service-connected left and right distal tibial stress fractures. Although addition diagnoses were identified, no change in the Veteran's service-connected diagnosis deemed necessary, to include as due to worsening symptoms. While the Board recognizes the Veteran's subjective belief that his bilateral knee condition is causally related to active service, to include as due to his service-connected bilateral distal tibial fractures; the evidence of record does not support a finding of "nexus." Similarly, the Board has fully considered the favorable physical therapist's opinion. However, the conclusions asserted were merely conclusory and failed to identify any supportive diagnostic findings or related rationale. Under the circumstances, the Board accords more probative weight to the VA examiner's opinion as they reflect a review of the Veteran's full medical history, appropriate diagnostic testing, and provided conclusions that were reasonably drawn from the record. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for bilateral knee condition, to include as secondary to service-connected bilateral distal tibial stress fractures must be denied. 4. Entitlement to service connection for bilateral pes planus, to include as secondary to service-connected bilateral distal tibial stress fractures The Veteran contends that he is entitled to service connection for bilateral pes planus, to include as secondary to service-connected bilateral distal tibial stress fractures. However, as discussed in more detail below, the preponderance of the evidence is against his claim. Service treatment records found no evidence of a bilateral foot abnormality at enlistment. In fact, the Veteran's arches were described as normal. Only signal reference to right ankle pain was reported in August 1999. No bilateral foot disability was reported at separation. Post-service treatment records show complaints of ankle pain in March 2014. A physical therapist evaluation documented pes planus with loading of the bilateral feet. Thereafter, impressions were taken to fit the Veteran for custom orthotics. On examination in December 2016, a current diagnosis of bilateral flat foot or pes planus was indicated. During the clinical interview, the Veteran reported participation in intense physical drills, to include running. As a result of those activities, he suffered bilateral shin splints. A bone scan confirmed a diagnosis of bilateral tibial stress fractures. Current symptoms include increasing pain with prolonged walking, standing, and running. According to the Veteran, his pain has become unbearable over time. Pain was described as throbbing. A functional impact was described as an inability to exercise without pain. Range of motion testing revealed, pain accentuated with use and manipulation. Evidence of swelling was also noted. No calluses were observed, bilaterally. Longitudinal arch height was described as decreased with weight-bearing. The weight bearing line fell over the medial to the great toe, bilaterally. Functional loss and limitation of motion was described as pain on movement, non-weight bearing, swelling, disturbance of locomotion, interference with standing, instability of station, and lack of endurance. Pain limits functional ability as to driving, walking, standing. Following the clinical evaluation, the examiner opined that it is less likely than not that the Veteran's bilateral flatfoot condition is proximately due to or the result of bilateral distal tibial stress fracture. In support of the stated conclusion, the examiner noted that there was no documentation of flat feet or pes planus during active service. During the current examination, only a mild decrease in arch was observed. Pursuant to a May 2020 Board remand decision, the Veteran was afforded an additional VA examination as the previous opinion was deemed insufficient for adjudicative purposes. Specifically, the examiner failed to address the Veteran's reports of chronic symptomatology in his bilateral feet which dates back to basic training. Further, worsening symptoms were suggested as causally related to his service-connected bilateral distal medial tibia fracture. On examination in September 2020, current diagnoses included bilateral pes planus and plantar fasciitis. During the clinical evaluation, the Veteran reported an onset of foot pain during basic training due to running and intensive physical drills. Current symptoms pain described as include constant, sharp, and tightness in feet. Prolonged walking and standing increases his pain. Frequent breaks to rest are often required. Pain and discomfort persist during periods of rest. The Veteran reported an inability to use insoles or arch supports. He acknowledged use of Aleve to treat pain. Flare-ups occur with prolonged walking and standing; and requires frequent rest breaks. On physical examination, pain was reported with use and manipulation of the bilateral feet. There was no evidence of swelling or calluses. Use of arch support and orthotics were unable to resolve his pain. Extreme tenderness impacted the plantar surfaces of the bilateral feet. Decreased longitudinal arch height was observed with weight bearing, bilaterally. There was no objective evidence of marked deformity of the bilateral feet or any other lower extremity causing alternation of the weight bearing line. There was also no evidence of inward bowing of the Achilles' tendon, marked inward displacement, or severe spasm of the Achilles' tendon (right hindfoot) on manipulation of one or both feet. No history of surgery was indicated. Pain causes functional loss in the bilateral feet. Additional factors contributing to the Veteran's disability include bilateral foot pain on movement, to include with weight bearing and non-weight bearing. Pain also impacts dorsiflexion and plantar flexion of the bilateral feet. No other pertinent physical findings were identified. Diagnostic imaging was not performed in connection with the current examination. A functional impact was described as a limited ability to run, jump, and stand for prolonged periods, or participate in high impact activities. Considering the Correia factors, pain was observed with weight-bearing and non-weight bearing of passive motion. Pain impacted the plantar and dorsiflexion of the bilateral feet. Following the clinical evaluation, the examiner opined that it is less likely than not (less than 50 percent probability) that the Veteran's pes planus and plantar fasciitis are proximately due to or the result of the Veteran's service-connected bilateral distal tibia fractures. In support of the stated conclusion, the examiner noted that persons with structural foot problems, such as very high arches or very flat feet, have an increased risk for developing plantar fascitis. The plantar fascia is designed to absorb the high stresses and strains placed on the feet over time. Sometimes, excessive pressure damages or tears the tissues. The body's natural response to injury is inflammation, which results in the heel pain and stiffness of plantar fasciitis. Flat footedness can occur as an inherited condition or result from an injury or repetitive stress which leads to the flattening of the arches in the foot. Flat feet and plantar fasciitis are caused by direct impact and repeated stress to the feet. The feet are the first things to hit the ground when walking, standing or running and act as the shock absorbers during high impact activity. These conditions are likely related to direct continuous stress to the feet and less likely than not attributed to residual pain in the distal tibias caused by previous stress fractures. Thus, the Veteran's bilateral foot conditions are separate and distinct from his service-connected distal tibia stress fractures. Considering the forgoing, the Board finds that service connection is not warranted for the Veteran's bilateral pes planus, to include as secondary to service-connected bilateral distal tibial stress fractures. In making all determinations, the Board has fully considered all lay assertions and medical evidence of record. Generally, the Veteran is deemed competent to report on his current symptoms and their onset. However, the record is silent for evidence showing that he possesses the specialized skills and expertise necessary to render complex medical opinions or opine as nature and etiology of his current symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377. Further, mere conclusory or generalized lay assertions that an in- service event or illness caused a current disability are insufficient to establish nexus in the absence of competent medical evidence. Waters v. Shinseki, 601 F.3d 1274, 1278. In this case, the medical evidence confirms that the Veteran has a current diagnosis of bilateral pes planus and plantar fasciitis. Service treatment records are silent for any complaints of bilateral foot conditions or any related diagnosis. Post-service treatment records show complaints of bilateral foot pain beginning in March 2014. A physical therapy treatment record suggested a correlation between the Veteran's lower extremity conditions and his service-connected bilateral tibia stress fractures. In multiple VA examinations, the Veteran complained of bilateral foot pain, limited motion, and difficulty with prolonged walking and standing. However, at no time has his bilateral foot condition been etiologically related to his service-connected distal tibial stress fractures. Moreover, the Veteran's bilateral foot conditions were deemed separate and independent from the Veteran's service-connected bilateral distal tibial stress fractures. The identified foot conditions were deemed more likely related to heredity and/or increased stress/shock absorption over time. While the Board recognizes the Veteran's subjective belief that his bilateral pes planus is causally related to active service, to include as due to his service-connected bilateral distal tibial fractures; the evidence of record does not support a finding of "nexus." Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to service connection for bilateral pes planus, to include as secondary to service-connected bilateral tibial stress fractures must be denied. Increased Ratings, Generally Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4 (2018). The Board determines the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, and the assigned rating is based, as far as practicable, upon the average impairment of earning capacity in civil occupations. 38 U.S.C. § 1155 (2014); 38 C.F.R. §§ 4.1, 4.10 (2018). Where entitlement to compensation has already been established and an increase in the assigned evaluation is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Although the recorded history of a particular disability should be reviewed in order to make an accurate assessment under the applicable criteria, the regulations do not give past medical reports precedence over current findings. Id. The Court has held that staged ratings are appropriate for initial rating and increased rating claims when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). When all the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 5. Entitlement to an evaluation in excess of 10 percent disabling for service-connected bilateral distal tibial stress fracture The Veteran contends that he is entitled to a higher evaluation for his service-connected bilateral distal tibial stress fracture. As discussed in more detail below, the preponderance of the evidence is against his claimed. The Veteran's bilateral distal tibial stress fractures are rated pursuant to 38 C.F.R. § 4.71a, Diagnostic Code 5299-5262, as analogous to impairment of the tibia and fibula. Generally, hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code shown after the hyphen to identify the basis for the evaluation assigned; disabilities requiring rating by analogy will be coded with the numbers of the most closely related body part and "99." In such cases, the hyphenated diagnostic code may be read to indicate that an unlisted musculoskeletal disorder is the service-connected disorder, and it is rated as if the residual condition is manifested by impairment of the tibia and fibula under Diagnostic Code 5262. Pursuant to Diagnostic Code 5262, a 10 percent rating is warranted for malunion of the tibia and fibula with slight knee or ankle disability; a 20 percent rating is warranted for malunion of the tibia and fibula with moderate knee or ankle disability; and 30 percent rating is warranted for malunion of the tibia and fibula with marked knee or ankle disability; and a 40 percent rating is warranted for nonunion of the tibia and fibula, with loose motion, requiring brace. Review of the record shows frequent complaints of pain, limited motion, and other impairments of the bilateral lower extremities. In March 2014, X-ray films revealed normal findings. Specifically, the left ankle mortise and the talar dome were observed as well maintained. The subtalar joint and calcaneus appeared normal. Similar observations are made on the right side. During a Board hearing in March 2020, the Veteran testified to worsening symptoms impacting the bilateral lower extremities. On examination in September 2020, current diagnoses included bilateral tendonitis and residuals of bilateral distal tibial stress fracture. During the clinical interview, the Veteran reported intermittent pain in both ankles which he relates to symptom progression. Other symptoms include creaking and popping in both ankles. Prolonged walking, standing and climbing exacerbates his symptoms. Use of Aleve provides some relief of his symptoms. Flare-ups of pain occur daily with physical activity. Functional loss was described as difficulty with prolonged walking, standing, and climbing stairs due to pain. Range of motion testing revealed dorsiflexion limited to 5 degrees and plantar flexion limited to 10 degrees, bilaterally. No additional functional loss or loss of range of motion was observed with repetitive use testing. However, pain was observed on examination with all ranges of motion, weight-bearing and it contributes to functional loss. Moderate localized tenderness was observed over the medial ankle, tibia, and fibula. It was deemed related to tendonitis and residuals of the Veteran's distal tibial fracture. There was no evidence of crepitus, muscle atrophy, or ankylosis. Pain, fatigue, and weakness caused functional loss in the right ankle and results in an additional loss of 5 degrees of plantar flexion. In the left ankle, pain and fatigue cause functional loss and results in an additional loss of 5 degrees of plantar flexion. No additional factors contribute to the Veteran's disability. Muscle strength testing was slightly reduced. Joint stability testing yielded normal findings. No complaints of shin splints were reported. No other pertinent diagnostic findings were indicated. The Veteran denied use of assistive devices. Diagnostic imaging was silent for any evidence of traumatic arthritis. A functional impact was described as a limited ability to run, jump, or engage in prolonged walking, standing, or high impact activities. As to the Correia factors, there was no objective evidence of pain with non-weight bearing of passive motion. Passive range of motion testing mirrored the findings for active motion, bilaterally. Following the clinical evaluation, the examiner noted that the Veteran suffers from two entirely separate conditions. Residuals of the bilateral distal tibial stress fractures resulted in point specific pain and tenderness overlying the bone of the distal tibia, bilaterally. This is located on the medial side of the lower leg just above the medial malleolus. Tendonitis was most significant on the lateral side of the ankle, underneath the lateral malleolus, bilaterally. Dull aching pain with pressure impacted the distal tibias, bilaterally. A sharp tight pain was localized at the ankles, suggestive of tendonitis. Following the clinical evaluation, the examiner reported an inability to distinguish the degree of limitation associated with each of the Veteran's lower extremity disabilities without resorting to speculation. In support of the stated finding, the examiner noted that the Veteran has frequently reported that all of his lower extremity conditions have gradually worsened over the years and negatively impact his ability to perform simple activities such as walking, standing and sitting. Sharp pain was reported with weight bearing at bilateral distal tibias, to include with palpation. Pain was also elicited with plantar and dorsiflexion of the ankles but there seems to be no pain with flexion and extension of the knees. No evidence of nonunion with loose motion or malunion was observed on diagnostic imaging. In April 2006, X-rays of bilateral tibia revealed normal bone mineralization. There was no evidence of acute fractures or subluxations. Soft tissues were described as unremarkable. The diagnostic impression revealed normal findings. In May 2006, an MRI with bone scan revealed a mild increased uptake along the lateral aspects of both tibial shafts, which possibly represents shin splints. The remainder of the bone scan was negative. While the Veteran's subjective complaints of shooting pains with numbness and tingling in lower parts of his legs were considered. There were no significant objective findings of neuropathy during the current examination. Sensation and deep tendon reflex testing revealed normal findings. The Veteran's muscle strength was slightly reduced in the knee and ankle with flexion and extension. The noted symptoms were deemed more likely related to pain at bilateral knee joints and bilateral distal tibias as opposed to a neurological deficit. Given this, the examiner reported an inability to diagnosis neuropathy. The Veteran's ability to ambulate normally is impacted by residual pain from his bilateral tibia fractures, bilateral pes planus, plantar fasciitis as well as chondromalacia of the right knee patella and patella femoral pain syndrome. All of these conditions appear to play a role in his difficulty with performing activities of daily living. In light of the above, the Board determines that a rating in excess of 10 percent for the Veteran's bilateral distal tibias fractures is not warranted. While the Veteran has frequently reported pain, limitation of motion, and difficulty with prolonged walking and standing due to his lower extremity conditions, he has only been granted service connection for one condition, bilateral distal tibias fractures. On examination, the examiner was unable to identify and isolate the symptoms attributable to his service connected versus his nonservice-connected conditions. Moreover, at no time has the medical evidence revealed favorable findings of ankylosis, instability, dislocated cartilage, or any additional impairment of the tibia and fibula, or genu recurvatum. Consequently, separate ratings pursuant to Diagnostic Codes 5256, 5257, 5258, and 5263, are not warranted. The Board recognizes the Veteran's competence to report on his observable symptoms and their worsening. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). However, the record is silent for any evidence that he possesses the required training and expertise to evaluate the nature and level of disability associated with each of his conditions as consistent with the diagnostic criteria listed under the appropriate diagnostic codes. Moreover, as the VA examiner has the requisite medical expertise to render a medical opinion which considers the degree of impairment caused by the Veteran's disability and his lay assertions, the Board accords more probative weight to the VA medical opinion with supportive rationale. In this case, the Board notes that the assigned rating of 10 percent contemplates some degree of pain, limited motion and functional impairments. However, and the medical evidence fails to show moderate symptomology attributable solely to the Veteran's service-connected bilateral distal tibias fractures, a higher evaluation is not warranted. (Continued on the next page) Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran's claim of entitlement to an evaluation in excess of 10 percent disabling for service-connected bilateral tibial stress fractures must be denied. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Whitaker, 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.