Citation Nr: 21027642 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 16-39 999 DATE: May 6, 2021 ORDER Service connection for a right arm disability, claimed as muscle strain, is denied. Service connection for a sinus disability, to include allergic rhinitis, is denied. Service connection for hemorrhoids is denied. FINDINGS OF FACT 1. The Veteran does not have a current right arm muscle injury and his current right carpal tunnel and right elbow epicondylitis had their onset many years following discharge from service and are not otherwise related to his pre-existing right arm fracture or any in-service injury or disease, including any in-service right arm muscle injury. 2. The Veteran does not have a current sinus disability and his current diagnosis of allergic rhinitis was not manifested during service, and is not otherwise due to any in-service disease or injury. 3. The Veteran's current hemorrhoid disability was not incurred in service, was not aggravated by service, and is not otherwise related to any in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for a right arm disability are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for a sinus disability are not met. 38 U.S.C. §§ 1110, 1111, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for hemorrhoids are not met. 38 U.S.C. §§ 1110, 1111, 1131, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Navy from June 1988 to June 1992. These matters come before the Board of Veterans' Appeals (Board) on appeal from a September 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio which, inter alia, denied service connection for a right arm, sinus, and hemorrhoid disability. The Veteran timely filed a notice of disagreement (NOD) in September 2014. A Statement of the Case (SOC) was issued in July 2015, but VA erroneously sent to an incorrect address. The Veteran was subsequently provided with a copy of the SOC, and timely filed a substantive appeal, via a VA Form 9, appeal to the Board of Veterans' Appeals in August 2016. In the VA Form 9, the Veteran limited his appeal to the claims decided herein. In September 2020, the Veteran testified before the undersigned Veterans Law Judge; a copy of the transcript is of record. In January 2021, the Board remanded the claims for further development. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected; if a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In addition, such chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101(3), 1112(a)(1), 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). A Veteran is presumed to have been sound upon entry into active service, except as to defects, infirmities, or disorders noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). In other words, "[w]hen no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry." Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). 1. Entitlement to service connection for a right arm disability The Veteran contends that he has a right arm muscle strain that had its onset during his active service. The Veteran reported that he first experienced issues in 1989 until he separated from service. He reported that his military occupational specialty required him to frequently take equipment from different locations. Additionally, he reported that he was toting tool bags with various types of tools in it. He reported that his dominant arm is his right arm and he constantly used it to pull and lift. In an April 2012 statement in support of claim, the Veteran reported arm pain that has been occurring off and on over the years without any apparent reason, and sometimes it lasts for months and then goes away. Service treatment records (STRs) reflect that the Veteran underwent an enlistment examination in May 1988. On the Report of Medical History, the Veteran checked the "yes" box for having had "broken bones." The narrative portion of the examination explains that the Veteran suffered a right arm fracture at age 7, that was treated with closed reduction and cast. No problems were noted at the time of entry. The Veteran was afforded another examination in October 1988, for overseas screening. On his Report of Medical History, the Veteran again checked the "yes" box corresponding to "broken bones." In the narrative portion of the examination report, it is again noted that the Veteran fractured his right arm, in 1982. The examiner specifically indicated that the past fracture was "NCD" (not considered disabling). Additionally, the report of medical examination notes a normal clinical evaluation for upper extremities. A medical surveillance questionnaire reflects that the Veteran complained of "pull muscle" in arms due to his work in construction from November 1988 to May 1991. The June 1992 separation report of medical examination notes a normal clinical evaluation for the upper extremities. The concurrent separation report of medical history reflects that the Veteran selected that he did not have any swollen or painful joints and did not have a painful or trick shoulder or elbow. A December 1994 VA medical certificate shows treatment for pain in the left hand and radiating to the elbow. There was no report of right arm pain. Post-service, medical treatment records from August 1997 reflect that the Veteran was seen for pain down the right arm and numbness in the hands for the past two months. During a July 2012 VA examination for the shoulder, the Veteran reported he has a deep right arm muscle pain starting around the elbow and traveling to the mid-forearm. A September 2013 VA examination report reflects that the Veteran did not have a diagnosis of a right arm disability. He reported deep right arm muscle pain starting around the elbow and traveling to the mid-forearm that causes functional impairment. The examiner noted that there was no abnormal right arm condition found to be attributable to military service. He reported that an enlistment examination documents a childhood fracture of the right arm. He concluded that there was no documented chronic right arm pain/condition in the STRs. In December 2013, a nerve conduction study was completed which revealed bilateral mild carpal tunnel syndrome. In a September 2014 statement, the Veteran reported that he received a nerve conduction test due to carrying tools and equipment up and down an aircraft carrier. In June 2016, VA treatment records reflect that the Veteran was seen in occupational therapy for his right shoulder, right knee pain, and neck pain. He did not report right elbow pain and right upper extremity strength was noted as 4/5 to all planes of the elbow. Additionally, range of motion of the right elbow was within normal limits with no pain noted on examination. In his August 2016 substantive appeal, the Veteran reported that he injured his right arm while carrying equipment during his service time as an Interior Communications Technician. He reported that the strain never healed. In October 2018, nerve conduction testing by the VA revealed bilateral carpal tunnel syndrome. During the September 2020 Board hearing, the Veteran reported that he first experienced muscle pain issues in 1989 with his right arm until he separated from service. He reported that he frequently had to take equipment from different locations. He testified that his dominant arm is his right arm and he constantly used it to pull and lift. He reported he was seen in service for his right arm. He testified that he was in current treatment for a tear in his shoulder. He testified that it has continued since service. In November 2020, the Veteran was diagnosed with lateral epicondylitis, right elbow. He reported right elbow pain which he says has been there for about 20 years. He is a retired electrician and reported that the pain is intermittent. A February 2021 VA examination report reflects that the Veteran does not have a diagnosis of a muscle injury. The examiner noted that the Veteran did not report a right arm muscle injury, but he stated that he remembers carrying a lot of heavy stuff during active duty and that must have hurt his right arm. The Veteran reported that he has not had therapy to the right elbow, no surgeries, no injections, or specific treatments for his claimed right muscle injury. He reported that he now has constant right elbow pain and is wearing a compression sleeve. He stated that the right elbow gets tired quickly, so he has to switch over to his left arm. He reported that he is scheduled for physical therapy for the right elbow. The examiner reported that the Veteran has right elbow epicondylitis, which is not a muscle injury but represents an inflammation at the point of ligament attachment. The clinician opined that the claimed right arm disability less likely as not incurred in or caused by the arm pain complaint during service. As rationale, he reported that the STR enlistment examination documents a history of closed reduction to right forearm at the age of seven. He reported that the 1992 exit examination did not show the presence of a right arm condition. In August 2018, nerve conduction testing revealed bilateral carpal tunnel syndrome. A September 2020 primary care physician note documents right forearm pain with a diagnosis of right elbow epicondylitis. There is no found chronic right arm disability found during or proximate to active duty. He reported that decades after discharge the Veteran has a diagnosis of bilateral carpal tunnel syndrome status post 2019 surgical release. Upon review of the evidence of record, service connection for a right arm disability is not warranted. Initially, while the Veteran's May 1988 entrance report of medical examination notes that the Veteran fractured his arm at age 7, neither the May 1988 narrative report nor the October 1988 narrative report found that there were any residuals associated with the childhood arm fracture. The October 1988 narrative report specifically indicated that it was not considered disabling "NCD." Furthermore, the Veteran's current complaints and reported muscle injury do not relate to the pre-existing right arm fracture, and the upper extremities had a normal clinical evaluation at the time of entry. Accordingly, the Veteran is presumed sound at entry with regard to any right arm muscle injury. The Veteran has a current diagnosis of carpal tunnel syndrome of the right upper extremity, as well as epicondylitis of the right elbow. Examinations reflect reduced strength of the right arm, and the Veteran's reports of pain. As the current disability requirement has been met, the question remains as to whether there is a nexus between the current disabilities and in-service complaint of muscle pull in the right arm. Based on a review of the available records and his particular expertise, the February 2021 examiner found that the Veteran's right arm disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Notably, the examiner confirmed that the Veteran did not have a current right arm muscle disability, but rather, it was a tendon disability in his elbow that was recently diagnosed in 2020. The examiner provided an adequate rationale for his conclusion that the Veteran's current disabilities were not related to the arm pain that the Veteran had in service. The examiner noted specific diagnoses of carpal tunnel and epicondylitis based on objective testing, and these are different disabilities, unrelated to the Veteran's in-service muscle injury. As the clinician explained the reasons for his conclusions based on an accurate characterization of the evidence of record, his opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). To the extent that the Veteran, including through his representative, has opined that his right arm disability had its onset during service, lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In this case, the Veteran's contentions as to the etiology of his right arm disability relate to an internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007) (witness capable of diagnosing dislocated shoulder). Additionally, the Veteran has consistently reported that he has a right arm muscle disability. The Board broadly considered the claim based on the diagnoses noted in the Veteran's treatment records. Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (a claim should not be limited to the disorder as characterized by the Veteran but must be characterized and addressed based on the reasonable expectations of the non-expert claimant and the evidence in processing the claim). However, the medical evidence of record consistently reflects that the Veteran did not have a current right arm muscle injury and the functional impairment seen on examination is the result of carpal tunnel syndrome and/or right elbow epicondylitis. Moreover, in 2020, the Veteran himself reported that he had right elbow pain for 20 years prior to his diagnosis of lateral epicondylitis, right elbow that was linked to his career as an electrician. The Veteran's statements are therefore not competent as to the current right arm diagnoses and their likely etiology. To the extent that the lay statements regarding continuity of pain are credible, the specific, reasoned opinion of the VA examiner is afforded greater probative weight than the Veteran's more general lay assertions. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim of service connection for a right arm disability. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for a sinus disability The Veteran contends that he has a sinus disability that had its onset during active service. He reported that he started having treatment for the sinus condition while in service and it has chronically continued since. He reported that during service, he was prescribed a nasal furosemide and different nasal sprays. He reported that he had to go into a gas chamber without a mask on. STRs do not show that the Veteran was treated for sinusitis during service. A May 1990 Dental Health Questionnaire indicates that the Veteran checked the "no" box corresponding to whether he had, or as ever had, sinus problems. In June 1990, the Veteran was seen for a sore throat, nasal congestion, bilateral earache, and productive cough. He denied bronchitis, sinusitis, or pneumonia in the past. There was no sinus tenderness noted on percussion. The assessment was URI (upper respiratory infection) and R/O (rule out) strep pharyngitis. In February 1992, he was seen for productive cough and was assessed with hemoptysis or pneumonia. He did not have sinus tenderness. In April 1992, he was seen as a follow up for hemoptysis and bronchitis. His cough was gone, he felt well, and he had no complaints. In the June 1992 separation report of medical history, the Veteran reported that he coughed up blood. In the coinciding separation report of medical examination, the Veteran had a normal clinical evaluation for sinus. Post-service, the Veteran was hospitalized in June 1996 after experiencing dry cough and fever. The discharge diagnosis was bilateral pneumonia. In January 1998, the Veteran was treated for a URI with symptoms of sore throat and sinus congestion. VA treatment records reflect that in 2009, the Veteran complained of sinus pain and was assessed with "other disease of nasal cavity and sinuses." In 2014, the Veteran was seen for sore throat and sinus congestion facial fullness postnasal drainage associated with productive cough of yellowish phlegm which started a week prior to that visit. He was assessed with rhinosinusitis with allergic component. In June 2015 acute sinusitis was noted in the problem list; however, it was subsequently noted that he was negative for sinus infection. In his September 2014 NOD, the Veteran reported that he continues to take medication for sinuses. In the August 2016 substantive appeal, the Veteran reported that he started having treatment for the sinus condition while in service and afterwards. He reported that it has been a chronic. During the September 2020 Board hearing, the Veteran reported a sinus condition began during bootcamp or shortly thereafter. He reported that he was seen in the military and was described a nasal furosemide and different nasals. He reported that he had to go into a gas chamber without a mask on. A February 2021 VA examination report reflects that the Veteran has a diagnosis of allergic rhinitis. He reported he uses Flonase as needed. He reported that he also has obstructive sleep apnea and using the machine seems to worsen his nasal (sinus) condition. The clinician opined that allergic rhinitis, claimed as a sinus disability, less likely as not incurred in or caused by the complaints of cough, congestion, and ear pain during service. As rationale, he reported that he reviewed the medical records and the STRs document acute respiratory condition during active duty without mention of a chronic sinus disease. A 2015 ear nose and throat specialist diagnosed allergies, not chronic sinus disease. There is no medical evidence found to indicate a chronic sinus condition during or proximate to active duty. He reported that acute medical conditions are self-limiting temporary conditions. He stated that medical record documents a long history of smoking with cough. He stated that smoking is a common cause of cough. Upon review of the evidence of record, service connection for a sinus disability is not warranted. Initially, the Veteran has a current diagnosis of rhinosinusitis with allergic component, acute sinusitis, and allergic rhinitis. The Veteran does not have a current disability of chronic sinusitis. Nonetheless, as the February 2021 examiner explained, the Veteran's claimed sinusitis symptoms are actually attributable to allergic rhinitis, and the Veteran, as a lay person, cannot be expected to know the difference. Because the Veteran has a current diagnosis of allergic rhinitis, that he sincerely believes is sinusitis, the Board must liberally construe the Veteran's claim to include all of his current symptoms as he is certainly capable of reporting his observable symptoms. See generally, Clemons v. Shinseki, 23 Vet. App. 1 (2009) (the scope of the claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record). Therefore the current disability element of service connection is met, and the question remains as to whether there is a nexus between the current disability and an in-service injury or disease. Based on a review of the available records and his particular expertise, the February 2021 examiner found that the Veteran's allergic rhinitis, claimed as a sinus disability, was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Specifically, the examiner noted the medical evidence does not note a chronic sinus disease, his in-service complaints were related to an acute respiratory condition, and he was eventually diagnosed with allergies years after discharge. He provided an adequate rationale for his conclusion that the Veteran's disability was not due to service. As the clinician explained the reasons for his conclusions based on an accurate characterization of the evidence of record, his opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). To the extent that the Veteran, including through his representative, has opined that his allergy disability had its onset during service, lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In this case, the Veteran's contentions as to the etiology of his allergies relate to an internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007) (witness capable of diagnosing dislocated shoulder). The Veteran's statements are therefore not competent in this regard. Moreover, the Veteran's STRs do not support the Veteran's contentions that he was treated for chronic sinusitis or chronic allergic rhinitis during service. In fact, the Veteran specifically denied having chronic symptoms related to allergies and sinusitis during service, and at the time of discharge. Accordingly, the Veteran's hearing testimony is inconsistent with his own self-reported history at the time of discharge. Accordingly, while the Veteran is competent to report observable symptoms such as nasal congestion and runny nose, his current assertions conflict with his reports more contemporaneous in time to service and service discharge. As such, more weight is accorded to the specific, reasoned opinion of the February 2021 VA examiner than the Veteran's more general lay assertions. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim of service connection for an allergic rhinitis and/or sinus disability. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for hemorrhoids The Veteran contends that his hemorrhoids had their onset during service. On his August 2016 VA Form 9, the Veteran reported that he had many treatments for hemorrhoids during service, and has had several issues with hemorrhoids since. STRs do not support the Veteran's contentions. A May 1988 entrance report of medical examination reflects a normal clinical evaluation for the anus and rectum. Reports of History from May 1988 and October 1988 do not indicate any reports of hemorrhoids or symptoms thereof. In May 1989 the Veteran reported chronic recurring pain sharp to internal anus at opening. He reported that this has been ongoing for seven years, and that his civilian doctor told him it was probably secondary to hard "BM" (bowel movements). The Veteran reported that bowel movements increase the pain and that he occasionally notices a small amount of blood on stools. On physical examination of the rectum, there were no observed internal or external hemorrhoids, or fissures noted. Sphincter tone was solid with mild tenderness to palpation (TTP). The prostate was solid but with tenderness to palpation (TTP). Flank and testicular tenderness on/to palpation was noted as insignificant. He was assessed with R/O (rule out) recurring internal hemorrhoids versus fissure, and he was provided with suppositories and stool softeners. He was instructed to increase his water intake and proper diet; and, he was told to return to the clinic (RTC) if symptoms increased and/or return to the clinic (RTC) in two weeks for a follow-up. There is no indication that the Veteran returned for a follow-up. In June 1991, the Veteran was seen for chest pain and stomach pain. He reported sharp pain beneath the rib which became worse when breathing. Pain was mainly to the right side of the stomach area. The Veteran reported some recent changes to his diet, but he also indicated that he had two normal bowel movements a day. A February 1992 examination of the rectum showed that there was no tenderness. At separation, there was a normal clinical evaluation for the anus and rectum. Post-service, medical treatment records from August 1997 reflect that the Veteran was seen for complaint of anal pain and abdominal pain around the ribs, relieved with passing gas. The diagnostic impression was flatulence and lactose intolerance. There was no indication that the Veteran had hemorrhoids. A September 2013 VA examination report reflects that the Veteran had a current diagnosis of hemorrhoids, and that he was diagnosed with hemorrhoids in 1991. The examiner noted a review of the claims file, which showed that the Veteran complained of, and was treated for, internal hemorrhoids, although the examiner does not specify when or where he was treated. The examiner also indicated that the Veteran currently continued to have rectal hemorrhoid swelling and soreness, with continued rectal bleeding. On examination, there were large external hemorrhoids. The examiner opined that external and internal rectal hemorrhoids are less likely as not caused or aggravated beyond natural progression by military service. As rationale, he reported that an enlistment examination does not mention a history of rectal hemorrhoids but when the Veteran experienced a hemorrhoid flare up secondary to his passage of hard stool, he reported a history of hemorrhoids treated by his civilian doctor prior to military service. Although not specified, the examiner was likely referring to the May 1989 STR that reflects exactly what the examiner pointed out that the Veteran presented with a seven year history of pain in the rectum, and reported that his civilian doctor told him that it was likely secondary to hard bowel movements. Thus, the examiner concluded that any hemorrhoid disability had its onset prior to service and the one single episode of purported hemorrhoids in service did not constitute aggravation. With regard to the notation of a hemorrhoid diagnosis in 1991, the STRs do not reflect a diagnosis of hemorrhoids in 1991. During a February 2014 gastroenterology consult, the Veteran denied hemorrhoids or change in bowel movements. An August 2014 colonoscopy revealed internal hemorrhoids. A July 2019 gastrointestinal consult revealed an impression of small internal hemorrhoids. A February 2021 VA examination report reflects that the Veteran was diagnosed with hemorrhoids in 2014; and, that the Veteran recalled having hemorrhoids during active duty. He reported treatment with soaks to manage the hemorrhoid pain. Since active duty, he uses over the counter creams and self-treats with a bath using Epsom salt. On examination, the Veteran had small or moderate external hemorrhoids as well as palpable internal hemorrhoids. The clinician opined that internal hemorrhoids, claimed as hemorrhoids, were less likely as not incurred in or caused by the notation of "hemorrhoids or fissures" during service. As rationale, he reported that medical records were reviewed, and the August 2014 colonoscopy showed small internal hemorrhoids. There is no found medical evidence of hemorrhoids during or proximate to active duty. The 2014 colonoscopy showed small internal hemorrhoids, decades after active duty. Upon review of the evidence of record, service connection for hemorrhoids is not warranted. At the outset, the STRs do not reflect that the Veteran had a pre-existing hemorrhoid disability, and the Veteran's 1989 admission that he had been experiencing anal pain, that increased with hard bowel movements, does not rebut the presumption of soundness at entry with respect to hemorrhoids. In this regard, there were no complaints, findings or diagnosis of hemorrhoids at the time of entry, and the Veteran's lay reports of pre-existing anal pain, alone, does not clearly and unmistakably show that the Veteran had a pre-existing hemorrhoid disability. It suggests that the Veteran had pre-existing anal pain brought on by hard stools, but at no time were hemorrhoids actually diagnosed at the time of the May 1989 treatment. That treatment report specifically indicates no (as reflected by the medical symbol of a "0" with a diagonal line through it) external or internal hemorrhoids, or fissures were noted. This is further clarified by the examiner's assessment of "R/O" (rule out) internal hemorrhoids vs fissures. External hemorrhoids, if present, would have been visible to the examiner, and thus, there was no need to rule those out. Accordingly, while the Veteran has a current diagnosis of hemorrhoids, diagnosed as of 2013, the preponderance of the evidence reflects that the current hemorrhoid disability had its onset many years following service discharge, and is not otherwise shown to be related to any in-service disease or injury. Although the Veteran reported that he was frequently treated for hemorrhoids in service, the STRs show only that he was treated on a single occasion for possible internal hemorrhoids in May 1989. Moreover, at the time of the May 1989 treatment, the Veteran was directed to follow up in two weeks, or sooner, if symptoms increased and the STRs do not show any follow-up treatment or any additional complaints or findings of hemorrhoids or anal pain. Thus, in-service internal hemorrhoids were never ruled in, or ruled out. Even if we assume, arguendo, that the Veteran's reported symptoms in May 1989 were ultimately determined to be internal hemorrhoids, the Veteran admittedly noted that he had been experiencing those symptoms for seven years; i.e. more than 5 years prior to entry into active duty. Thus, the single treatment during service in May 1989, by the Veteran's own self-reported history, does not represent an increase in severity of a pre-existing hemorrhoid disability during service beyond natural progression. As such, any pre-existing anal pain (which may, or may not, be a symptom of internal hemorrhoids, was not aggravated during service. A single flare-up does not constitute aggravation. The Veteran is competent to report ongoing observable symptomatology, such as anal pain and rectal bleeding; however, he is not competent to diagnose internal hemorrhoids, and there is no evidence that any external hemorrhoids had their onset during service or are otherwise related to service. Internal hemorrhoids require clinical examination by a medical professional with the requisite education and internal hemorrhoids are not observable to the lay person. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Moreover, the Veteran's current statements and testimony that he was treated for hemorrhoids on several occasions during service is inconsistent with the STRs, which, as noted above, note a single complaint of anal pain during service, and no report of any hemorrhoids at discharge, or for many years thereafter. Finally, the competent medical evidence weighs against the claim. The September 2013 VA examiner indicated that any in-service hemorrhoid disability pre-existed service and was not aggravated by service. The February 2021 VA examination report indicates that the first diagnosis of hemorrhoids was in 2014, and that the current hemorrhoids were less likely than not related to the in-service anal pain. There are no competent medical opinions to the contrary. More weight is accorded to the specific, reasoned opinions of the September 2013 and February 2021 VA examiners than the Veteran's unsupported lay assertions. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim of service connection for hemorrhoids. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Laroche, N. 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.