Citation Nr: 21030988 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 16-27 598 DATE: May 20, 2021 ORDER An application to reopen a claim of entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. An application to reopen a claim of entitlement to service connection for residuals of cold injury to the feet is denied. Entitlement to service connection for an acquired psychiatric disorder, other than PTSD, is denied. Entitlement to service connection for gout to include of the hands, elbows, and ankles is denied. Entitlement to service connection for a left wrist disability, to include carpal instability, is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection fora left hip disability is denied. Entitlement to service connection for a right hip disability is denied. Entitlement to service connection for a left leg disability is denied. Entitlement to service connection for a right leg disability is denied. Entitlement to service connection for a sinus disability, to include sinusitis, is denied. Entitlement to service connection for a headache disorder is denied. Entitlement to service connection a for left foot disorder, other than residuals of cold injury, is denied. Entitlement to service connection a for right foot disorder, other than residuals of cold injury, is denied. REMANDED Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection fora right wrist disability is remanded. Entitlement to an initial compensable rating for a left ankle disability is remanded. FINDINGS OF FACT 1. An August 2000 rating decision that denied entitlement to service connection for PTSD and bilateral foot frostbite was not timely appealed and became final. 2. Evidence received since the final August 2000 rating decision does not relate to an unestablished fact necessary to substantiate the claim for service connection for PTSD and residuals of a cold injury to the feet. 3. The preponderance of the evidence is against a finding that the Veteran's currently diagnosed acquired psychiatric disorder, other than PTSD, was initially manifested in service, nor was a psychosis shown within one year of separation from service, and the weight of the competent evidence is against finding a nexus between a post-service diagnosis of any psychiatric disorder and service. 4. The preponderance of the evidence is against a finding that a left wrist disability, a left knee disability, right foot disability, left foot disability, bilateral hip disorders, bilateral leg disabilities or gout, initially manifested in service; arthritis was not shown within one year of discharge from service, and; the weight of the competent evidence is against finding a nexus between a left wrist disability, a left knee disability, bilateral hip disorders, bilateral foot disorders, bilateral leg disabilities or gout, and service. 5. The preponderance of the evidence is against a finding that a sinus disorder, to include sinusitis, had onset in service, and the weight of the competent evidence is against finding a nexus between a post-service diagnosis of sinusitis and service. 6. The preponderance of the evidence is against a finding that the claimed headache disorder initially manifested in service, nor was it shown within one year of separation from service, and the weight of the competent evidence is against finding a nexus between a headache disorder and service. CONCLUSIONS OF LAW 1. Evidence received since the final August 2000 rating decision is not new and material and the claim for entitlement to service connection for PTSD is not reopened. 38 U.S.C. § 5108; 38 C.F.R. § § 3.156(c). 2. Evidence received since the final August 2000 rating decision is not new and material and the claim for entitlement to service connection for cold injury to the feet is not reopened. 38 U.S.C. § 5108; 38 C.F.R. § § 3.156(c). 3. The criteria for service connection for an acquired psychiatric disorder, other than PTSD, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 4. The criteria for service connection for gout to include of the hands, elbows, and ankles, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 5. The criteria for service connection for a left wrist disability, to include carpal instability, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 6. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 7. The criteria for service connection for a left hip disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 8. The criteria for service connection for a right hip disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 9. The criteria for service connection for a left leg disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 10. The criteria for service connection for a right leg disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 11. The criteria for service connection for a sinus disorder, to include sinusitis, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 12. The criteria for service connection for a headache disorder have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 13. The criteria for service connection for a left foot disability, other than cold injury to the foot, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. 14. The criteria for service connection for a right a foot disability, other than cold injury to the foot, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from June 1982 to May 1986. In January 2019 the Veteran testified at a personal hearing before the undersigned. Unfortunately, the transcript of that hearing was lost. In correspondence in December 2019, the Veteran was notified that the hearing transcript was lost. The Board notes that the December 2019 correspondence listed the wrong hearing date. Nonetheless, in April 2020, after being notified of the lost personal hearing transcript, the Veteran notified the Board of Veterans' Appeal (Board) that he did not want another personal hearing. Therefore, the Board finds that this appeal can being adjudicated without scheduling another personal hearing. In light of the above, the evidence has been reviewed in detail. In October 2020 the Board remanded the appeal for additional development, which has been completed. New and Material Evidence Claims Generally, if a claim for service connection has been previously denied and that decision became final, the claim can be reopened and reconsidered only if new and material evidence is presented with respect to that claim. 38 U.S.C. § 5108. "New" evidence is defined as existing evidence not previously submitted to agency decisionmakers. "Material" evidence means evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative, nor redundant of the evidence previously of record, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The Court interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." Shade v. Shinseki, 24 Vet. App. 110 (2010). For the purpose of establishing whether new and material evidence has been received, the credibility of the evidence, but not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Despite the determination reached by the RO, the Board must find new and material evidence in order to establish its jurisdiction to review the merits of a previously denied claim. See Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). 1. Whether new and material evidence has been submitted to reopen the claim for service connection for PTSD The Veteran's claim for service connection for PTSD was originally denied in June 2000, and in a subsequent rating decision in August 2000, the RO denied the claim for service connection for PTSD because there was no evidence of a diagnosis of PTSD associated to a verified in service stressor. The Veteran was informed of the decision and of his appellate rights, but he failed to timely appeal the August 2000 rating decision and it became final. 38 U.S.C. § 7105 ; 38 C.F.R. § §§ 3.156 (b); 20.302, 20.1103; see also Bond v. Shinseki, 659 F.3d 1362 (Fed. Cir. 2011); see also Buie v. Shinseki, 24 Vet. App. 242, 251-52 (2010). A final decision cannot be reopened unless new and material evidence is presented. 38 U.S.C. § 5108. The Veteran submitted a request to reopen his claim in 2014. At the time of the August 2000 rating decision, the evidence of record consisted of service treatment records, service personnel records, VA treatment records, and statements from the Veteran. The service treatment records showed that the Veteran was seen twice in December 1984 and March 1986, for episodes of situational adjustment disorder and depression due to martial separation and financial problems. When the Veteran was evaluated in connection with these episodes, the examiner found that the episodes were acute and transitory and there was no chronic psychiatric disability recorded, to include PTSD. Service personnel records show document instances of disciplinary action, including an Article 15 for being absent without official leave (AWOL) for 18 days and in May 1984. Also in the record, were VA mental health treatment records dated after 1999, that documented a diagnosis of major depressive disorder (MDD) and PTSD associated with the Veteran's reported stressor of witnessing his close friend killed in a drive by shooting in 1995, years after service. On mental health evaluation in August 1999, the Veteran related a history of depression for four years associated with financial problems and poor social support. Evidence received since the prior final denial includes VA treatment records that reflect mental health treatment. In September 2000, the Veteran reported several in-service stressors, including having to stand outside for guard duty during a blizzard, loading ammunition which was reportedly thought could explode, and hearing explosions from training exercises while he was in the barracks. The examiner at that time determined that the stressors did not meet the criteria to support a diagnosis of PTSD. Subsequent treatment records document PTSD due to nonmilitary stressors, including witnessing the death of a close friend in 1995 and seeing his house on fire in 2012. Subsequent treatment records show continued mental health treatment for these problems. A VA examination report dated February 2015, which recorded a diagnosis of MDD with anxiety less than likely as not related to military service, but rather associated with witnessing the death of a close friend in 1995. A diagnosis of PTSD was not confirmed by the examiner. Such evidence is "new" as it was not previously of record. Moreover, such evidence must be presumed credible for the purposes of new and material evidence analysis. Even assuming their credibility for new and material evidence analysis, the post-service treatment records are cumulative and cannot be considered new and material evidence. However, none of the evidence suggests a diagnosis of PTSD associated with a verified in service stressor. On the contrary, the VA opinion of record weighs against the claim. In a statement received in March 2019, the Veteran reported that during service, sometime in 1985, he was at a dance club when a fight broke out and shots were fired injuring another man. Although the additional evidence is new, the Board does not find it to be material. In this regard, the Board notes that the objective evidence of record, including the Veteran's service personnel records and service treatment records, do not support the Veteran's allegations and the reported incident is not documented in his service treatment records or any other contemporaneous records. Therefore, the statement is not material for the purposes of reopening the Veteran's claim for service connection for PTSD. It is important for the Veteran to understand that even if the Board reopened the claim, the overwhelming evidence of record provides significant evidence against the claim, providing the basis to deny the claim once again. The Board can not ignore significant factual evidence against the Veteran key contention. Accordingly, the Board finds that new and material evidence has not been submitted and the claim for service connection for PTSD is not reopened. See Annoni v. Brown, 5 Vet. App. 463 (1993). 2. Whether new and material evidence has been submitted to reopen the claim for service connection for residuals of cold injury to the feet The Veteran's claim for service connection for residuals of cold injury to the feet was originally denied in June 2000 and in August 2000, on the basis that there was no evidence of a cold injury to the feet in service, or a diagnosis of residuals of bilateral foot frostbite. The Veteran was informed of the decision and of his appellate rights, but he failed to timely appeal the August 2000 rating decision and it became final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. At that time, the record contained the Veteran's service treatment records and VA treatment records which failed to show a cold injury to the feet or residuals thereof. The evidence received since the August 2000 rating decision includes additional VA treatment records and a January 2015 VA examination report, which fail to document a diagnosis of residuals of bilateral foot frostbite. None of the evidence suggests that the Veteran has a disability manifested by residuals of a cold injury to the feet. Accordingly, while new, this evidence is not material to the claim and some of it provides evidence against the claim. Simply stated, once again the Veteran is repeating his prior claim. As the Veteran has not fulfilled his threshold burden of submitting new and material evidence to reopen the finally disallowed claim for service connection for residuals of cold injury to the feet, the benefit-of-the-doubt doctrine is not applicable. Annoni, 5 Vet. App. at 467. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting service, was aggravated therein. 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). To establish service connection for a disability, there must be competent evidence of the following: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Shedden, 381 F.3d at 1167; Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)). In many cases, medical evidence is required to meet the requirement that the evidence be "competent". However, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Service connection for certain chronic diseases, including psychosis and arthritis, may be presumed to have been incurred in service by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Such a chronic disease is presumed under the law to have had its onset in service even though there is no evidence of that disease during the period of service. 38 C.F.R. § 3.307(a). When a chronic disease is shown in service, sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303 (b). To be "shown in service," the disease identity must be established and the diagnosis must not be subject to legitimate question. Walker v. Shinseki, 708 F.3d 1331, 1335 (Fed. Cir. 2013); see also 38 C.F.R. § 3.303 (b). There is no "nexus" requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease. Walker, 708 F.3d at 1336. Certain evidentiary presumptions - such as the presumption of service incurrence for certain diseases, which manifest themselves to a degree of disability of 10 percent or more within a specified time after separation from service - are provided by law to assist veterans in establishing service connection for a disability or disabilities. 38 U.S.C. §§ 101, 1112; 38 C.F.R. § 3.304 (b), 3.306, 3.307, 3.309. In evaluating the evidence, the Board has been charged with the duty to assess the credibility and weight given to evidence. Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). Indeed, the Court has declared that in adjudicating a claim, the Board has the responsibility to do so. Bryan v. West, 13 Vet. App. 482, 488-89 (2000). In doing so, the Board is free to favor one medical opinion over another, provided it offers an adequate basis for doing so. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 3. Entitlement to service connection for an acquired psychiatric disorder, other than PTSD The Veteran seeks service connection for an acquired psychiatric disorder, other than PTSD. In this case, the medical evidence shows that the Veteran has been diagnosed with an acquired psychiatric disorder, to include MDD. The service treatment records show that the Veteran was seen twice in December 1984 and March 1986, for episodes of situational adjustment disorder and situational depression due to marital and financial problems. When the Veteran was evaluated in connection with these episodes, the examiner found that the episodes were acute and transitory and there was no chronic psychiatric disability recorded, to include PTSD. Service personnel records document instances of disciplinary action, including an Article 15 for being AWOL for 18 days and in May 1984. After service, the Veteran sought mental health treatment in 1999. On VA mental health evaluation in August 1999, the Veteran reported being depressed for approximately four years. He endorsed stress from financial problems. The Veteran also described having witnessed a close fiend killed in a drive by shooting in 1995. He was diagnosed MDD associated with significant debt, insufficient income and only fair social support. Subsequent treatment records document ongoing treatment for an acquired psychiatric disorder. The records show that the Veteran's symptoms of mental health disorders were associated with situational stressors, to include the Veteran's financial problems, unemployment, legal problems, homelessness and lack of social support. Importantly, his service was not cited. Thus, there is no evidence of psychosis in service or within one year following discharge from service. On the contrary, the Veteran's service treatment records reflect that his psychiatric symptoms resolved with treatment and were situational, as opposed to chronic, in nature. Therefore, the Board finds that the service treatment records do not support a finding of a chronic psychiatric condition. Moreover, the Veteran's mental health symptoms associated with the currently diagnosed acquired psychiatric disorders have been attributed to situational stressors, to include the Veteran's financial problems, housing and employment issues, not related to service. Simply stated, the post-service treatment records provide particularly negative evidence against this claim, clearly indicating post-service caused of the problem at issue. Competent evidence linking the current disability to service or a service-connected disability is needed to substantiate the claim. The Veteran underwent a VA examination in February 2015. After review of the file and an examination of the Veteran, he was diagnosed as having MDD. The examiner opined that the Veteran's depression and anxiety were less than likely as not related to the adjustment disorder noted in service, because the Veteran's in-service mental health condition was related to his marital and financial stressors that were situational at the time and had since resolved. The examiner noted that the current depression and anxiety were unrelated to situational stressors noted in service. Instead, the examiner attributed the Veteran's depression and anxiety to a club shooting that occurred in 1995, and resulted in his best friend being shot next to him. The Board finds the 2015 VA examiner's opinion to be highly probative. The opinion was based on a thorough review of the claims file, including the service treatment records and examination of the Veteran. The examiner cited to the service treatment records that documented treatment for a situation adjustment disorder, and the opinion is consistent with other evidence of record. Moreover, the examiner provided adequate rationale for the opinion. Accordingly, the VA examiner's opinion is entitled to great probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). To the extent the Veteran asserts that he developed an acquired psychiatric disorder due to service, he is certainly competent to report as to the observable symptoms they experience and their history, but he cannot diagnose because of the medically complex nature of such a diagnosis. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); See Jandreau, 492 F.3d 1372, 1377. The ultimate questions in this case are related to an internal medical process which extends beyond an immediately observable cause and effect relationship. Id. The Board finds that the specific, reasoned opinion of the VA examiner of greater probative weight than the more general lay assertions in this regard. The examiner has training, knowledge, and expertise on which they relied to form the opinions, and the examiner provided rationale for the conclusions reached. Simply stated, both the best medical evidence in this case, and the facts of this case, provide highly probative evidence against this claim, indicating a problem than began many years after service ended in 1986. Based on the foregoing, the Board finds the preponderance of the probative and persuasive evidence against a finding that acquired psychiatric disability, to include major depressive disorder, arose in service or is etiologically related to service or any incidents therein. Moreover, a psychosis was not shown within one year following discharge from service, and the provisions regarding continuity are not for application. See Walker, 708 F.3d at 1340 (holding that only conditions listed as chronic diseases in 38 C.F.R. § 3.309 (a) may be considered for service connection under 38 C.F.R. § 3.303 (b). In sum, as the Board finds that the weight of the objective, persuasive evidence is against a finding that any psychiatric disorder is causally related to service, the Board finds that the preponderance of the evidence is against the claim that any psychiatric disorder was incurred in or in any way related to service. As such the claim must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55-56. 4. Entitlement to service connection for gout to include of the hands, elbows, and ankles 5. Entitlement to service connection for a left wrist disability, to include carpal instability 6. Entitlement to service connection for a left knee disability 7. Entitlement to service connection fora left hip disability 8. Entitlement to service connection for a right hip disability 9. Entitlement to service connection for a left leg disability 10. Entitlement to service connection for a right leg disability The Veteran seeks service connection for a left wrist disability, a left knee disability, bilateral hip disorders, bilateral leg disabilities, and gout affecting the legs, hands, elbows and ankles. He generally asserts that he incurred the claimed disabilities due to wear and tear incurred in the performance of his duties as an ammunition specialist, which required him to lift and carry heavy ammunition boxes, as well as due to physical exercise in service. The Veteran has been diagnosed with a left wrist disability, a left knee disability, bilateral hip disorders, and gout affecting the affecting the legs, hands, elbows and ankles. Thus, the remaining question before the Board is whether such disabilities are related to service. The Veteran's service treatment reports fail to document complaints or findings consistent with a left wrist disability, a left knee disability, bilateral hip disorders, bilateral leg disabilities or gout. After service, treatment records in 2000 show that the Veteran was diagnosed with right lateral epicondylitis. He was diagnosed with gout in 2001. Imaging studies of the right hip in 2001 noted minimal degenerative changes. In June 2007, the Veteran injured his left wrist while lifting a keg. He denied any left wrist problems before that injury. Imaging studies revealed degenerative joint disease and a complete tear of the scapholunate ligament. Surgery was recommended. Subsequent treatment records document complaints of pain in multiple joints, including the feet, ankles and knees, which were associated with gout, along with wrist swelling and pain. Thus, the Veteran was not shown to have arthritis of the left wrist, left knee, hips, hands or elbows, in service or within one year following discharge from service, as such, service connection cannot be established for arthritis on a presumptive basis. 38 U.S.C. § 1112 ; 38 C.F.R. §§ 3.307, 3.309. Here, there is no evidence of a left wrist disability, a left knee disability, bilateral hip disorders, bilateral leg disabilities or gout in service or for many years after discharge therefrom. In so noting, the Board recognizes that the mere absence of medical records is not dispositive as to the question of continuity; the lay evidence must be considered as well. See Buchanan v. Nicholson, 451 F.3d at1335. If, however, it is determined based on reliable evidence, that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). To the extent the Veteran is asserting continuity of symptomatology from service, the Board finds such statements inconsistent with the overall record, to include the service treatment records. Thus, the Veteran has not adequately shown that his claimed left wrist disability, a left knee disability, bilateral hip disorders, bilateral leg disabilities and gout had onset in service and continued since service. On the question of a nexus between the left wrist disability, a left knee disability, bilateral hip disorders and service, the evidence weighs against the claims. On VA examination in January 2015, the examiner noted left carpal instability following a 2007 injury incurred while the Veteran lifted a keg. The examiner opined that the left wrist disability was less likely than not incurred in or caused by the claimed in-service injury, event or illness. In support of the opinion, the examiner noted that there was no evidence of a left wrist injury or condition prior to the 2007 lifting injury. Concerning the hips and left knee, the examiner noted diagnoses of osteoarthritis. The Veteran reported onset pain and swelling of the left knee and hips since service. The examiner opined that degenerative changes of the left knee and hips were less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that there was no evidence in service of a left knee or hip injury or disability. The examiner noted symmetric bilateral degenerative changes of the hips and degenerative changes of the left knee which were consistent with aging. The examiner considered the complete record and the Veteran's contentions and provided an explanation as to why the evidence does not support a finding that his left wrist, left knee and bilateral hip disorders were due to service. Finally, the VA examiner's opinion was internally consistent and consistent with other evidence of record and is of significant probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). In this regard, the Board must find that the service and post-service treatment records provide particular negative evidence against the claims. Significantly, there is no competent medical opinion linking the left wrist, left knee and bilateral hip disorders to any aspect of the Veteran's service. The Veteran has only provided bare assertions which are outweighed by the VA examiner's opinions. The Veteran is certainly competent to report as to the observable symptoms she experiences and their history, but he cannot self-diagnose because of the medically complex nature of such a diagnosis. Layno v. Brown, 6 Vet. App. 465 (1994); See also Buchannan, supra; Jandreau, supra. The ultimate questions in this case are related to an internal medical process which extends beyond an immediately observable cause and effect relationship. Id. A VA examination or medical opinion regarding the etiology of gout, affecting the legs, hands, elbows and ankles, is not indicated as there is no suggestion that the Veteran's gout may be associated with service. Again, there is no competent evidence of gout in service or for more than a decade following service discharge until it was initially diagnosed in 2001. Moreover, there is no competent and probative evidence to show that the Veteran had a left wrist disability, a left knee disability, bilateral hip disorders, bilateral leg disabilities, or gout of the legs, hands, elbows and ankles, during or contemporaneous with service and no competent and probative evidence that his claimed disorders are related to his service. Given the foregoing, the Board finds that the preponderance of the evidence is against the claims for service connection for a left wrist disability, a left knee disability, bilateral hip disorders, bilateral leg disabilities, and gout of the the legs, hands, elbows and ankles, and that the claims must be denied. See 38 U.S.C. § 5107 (b); Gilbert, supra. 11. Entitlement to service connection for a sinus disorder 12. Entitlement to service connection for a headache disorder The Veteran seeks service connection for a sinus disability, to include sinusitis, and a headache disorder. The evidence shows that the Veteran has been diagnosed with chronic sinusitis. The record is unclear as to whether the Veteran currently suffers a headache disorder. Nonetheless, the discussion below will assume (but not concede) for purposes of argument that the Veteran has a headache disability. The service treatment records show that the Veteran was seen for sinus complaints in November 1982, and again on a second occasion. The Veteran was seen in March 1986 for complaints of headaches associated with stomach cramps and side pain. It was noted that the Veteran's breath smelled of alcohol. Treatment records since approximately 2014, noted allergic rhinitis treated with sinus flush. Concerning headaches, post-service treatment records are negative for a diagnosed headache disorder and the Veteran mostly denied headaches until approximately 2017, when he presented occasional complaints of headaches that were associated with cold symptoms and hypertension. A chronic headache and/or sinus disability, to include sinusitis, was not shown in service, or within one year of discharge from service in 1986. Rather, the Veteran's sinus and headache complaints noted in the service treatment records appear to have been transient and to have resolved with treatment. To the extent the Veteran is asserting continuity of symptomatology from service, the Board finds such statements inconsistent with the overall record. He has not credibly shown that his claimed headache and sinus disabilities were incurred in service and continued since service as this is inconsistent with the service treatment records and post-service medical evidence. On the question of a nexus between the claimed a headache disorder and/or sinus disability, to include sinusitis, and service, the evidence weighs against the claims. On VA sinus examination in January 2015, the Veteran reported onset of symptoms associated with sinusitis in service. Following an examination of the Veteran and a review of the evidence, the examiner diagnosed chronic sinusitis and opined that a sinus condition was less likely than not condition that was incurred in or caused by the sinus problems during service. The examiner explained that a chronic sinus condition was not diagnosed or documented in the service treatment records or post-service treatment records. Concerning the Veteran's claimed headache disorder, the Veteran reported really severe headaches that he associated with his sinus condition. He reported onset of headaches in 1983, during service. The examiner noted that the Veteran had never been diagnosed with a headache disability. Following an examination of the Veteran and a review of the evidence, the examiner opined that it was less likely than not that the claimed headache disorder was incurred in or caused by the sinus problems during service. While the service treatment records documented complaints of headache, it was associated with acute viral syndrome. No chronic headache was condition diagnosed or documented in service treatment records or post-service discharge, and on examination in 2013 the Veteran denied any headaches. After consideration of all the evidence of record, the Board finds that the preponderance of the evidence is against finding that entitlement to service connection for headaches or a sinus disorder, to include sinusitis, is warranted. The Board notes the Veteran's statements regarding his in-service symptoms of headaches and sinus problems, and ongoing manifestations which he is competent to report. However, the Veteran's lay statements must be weighed against the other evidence of record. See Jandreau, supra. While the Veteran asserts that he has headache and sinus disorders that were incurred in service, the Board notes that the diagnosis of these conditions requires clinical testing and medical expertise, and cannot simply be diagnosed by lay observation alone. The Board notes that the Veteran has not provided a medical opinion nor supported his contentions with any examination reports or findings that he has headaches and sinusitis associated with any aspect of the Veteran's service. Compared to the VA examination report of record, the VA examiner reviewed the claims file, examined the Veteran, review medical literature, and provided etiological opinions with rationale. Here the Veteran has only provided bare assertions which are outweighed by the medical examinations of record. The Board finds that the objective medical evidence is more probative than the lay statements of record. The Board notes VA examination reports showed that the Veteran's claimed headache and sinus disorder, to include sinusitis, were not related to service. The examiner noted that despite complaints of notions of headaches and sinus issues in service, and with consideration of his current complaints, no evidence of a chronic headache or sinus disorder was recorded. The VA examination reports of record are high probative value, and the Veteran's statements are outweighed by these reports and weigh against the claims. As such, the Board finds that service connection for headache and sinus disorders, to include sinusitis, is not warranted, and the claims are denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. 13. Entitlement to service connection for a left foot disability, other than a cold injury 14. Entitlement to service connection for a right foot disability, other than a cold injury The Veteran seeks service connection for right and left foot disabilities, other than residuals of cold injuries to the feet. The service treatment records show that the Veteran was seen for falling arch of right foot in December 1982, and he was given arch support. In August 1985, he was seen for right foot numbness after a box fell on his foot three months earlier. Imaging studies revealed no abnormalities. The remainder of the service treatment records contain no complaint, history or findings consistent with a chronic right or left foot disability. Treatment records since approximately 2001, noted bilateral foot pain associated with plantar fasciitis, as well as gout. Thus, a chronic right and/or left foot disorder was not shown in service, or for approximately 15 years after discharge from service in 1986, and arthritis was not shown within one year of service discharge. Therefore, the right foot complaints noted in the service treatment records appear to have been transient and to have resolved with treatment. To the extent the Veteran is asserting continuity of symptomatology from service, the Board finds such statements inconsistent with the overall record. He has not credibly shown that his bilateral foot disabilities were incurred in service and continued since service as this is inconsistent with the service treatment records and post-service medical evidence. He has filed several claims without a basis for the belief that they are the result of service. On the question of a nexus between the claimed right and left foot problems and service, the evidence weighs against the claims. On VA examination in January 2015, the Veteran reported that he dropped a box of ammunition on his left foot during active service. He endorsed bilateral foot pain, greater on the left than the right. Reportedly he was told that he had bone spurs. He localized the pain to his ankles, heels and toes. The examiner diagnosed bilateral plantar fasciitis and opined that the condition was less likely than incurred in or caused by the claimed in-service injury, event or illness. The examiner explained that the Veteran's current right and left foot diagnosis, bilateral plantar fasciitis, was a condition that was separate, different and independent from the complaints noted in active service. After consideration of all the evidence of record, the Board finds that the preponderance of the evidence is against finding that entitlement to service connection for a right or left foot disorder, diagnosed as plantar fasciitis, is warranted. The Board notes the Veteran's statements regarding his in-service symptoms of foot pain, and ongoing manifestations, which he is competent to report. However, the Veteran's lay statements must be weighed against the other evidence of record. See Jandreau, supra. While the Veteran asserts that he has right and left foot disabilities that were incurred in service, the Board notes that the diagnosis of these conditions requires clinical testing and medical expertise, and cannot simply be diagnosed by lay observation alone. The Board notes that the Veteran has not provided a medical opinion nor supported his contentions with any examination reports or findings that he has right and left foot disabilities associated with any aspect of the Veteran's service. Compared to the VA examination report of record, the VA examiner reviewed the claims file, examined the Veteran and provided an etiological opinion with rationale. Here the Veteran has only provided bare assertions which are outweighed by the medical examination of record. The Board finds that the objective medical evidence is more probative than the lay statements of record. The Board notes VA examination reports showed that the Veteran's claimed right or left foot disorder, to include plantar fasciitis, were not related to service. The VA examination report of record are high probative value, and the Veteran's statements are outweighed by these reports and weigh against the claims. As such, the Board finds that service connection for right or left foot disorder, to include plantar fasciitis, is not warranted, and the claims are denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. REASONS FOR REMAND 1. Entitlement to service connection for a right knee disability is remanded. 2. Entitlement to service connection fora right wrist disability is remanded. The Veteran seeks service connection for right knee and right wrist disabilities. Generally, a veteran is presumed sound upon entry into service, except as to disorders noted at the time. 38 U.S.C. § 1111, 1132. This is known as the presumption of soundness. To rebut the presumption, VA must show by clear and unmistakable evidence that (1) the veteran's disability existed before her military service, and (2) that the pre-existing disability was not aggravated during service. Wagner v. Principi, 370 F.3d 1089, 1097 (Fed. Cir. 2004). The clear-and-unmistakable evidence standard is an "onerous one." Horn v. Shinseki, 25 Vet. App. 231, 234-235 (2012). To qualify as "clear and unmistakable," evidence "cannot be misinterpreted and misunderstood, i.e., it [must be] undebatable." Vanerson v. West, 12 Vet. App. 254, 258 (1999). In other words, the evidence is not clear and unmistakable if the conclusion is debatable. See id. The service treatment records show that on enlistment examination the examiner noted a history of medial right knee arthropathy. A May 1985 record reported a history of right wrist fracture at the age of 14, and right knee ligament repair in 1974. At that time, the Veteran denied knee swelling, pain or giving way. In June 1983 the Veteran was seen for right knee retropatellar pain syndrome. In September 1985 the Veteran was treated at the emergency room for a sprained right wrist. The Veteran underwent a VA examination in January 2015 to determine if the Veteran right knee disability was related to service. The examiner noted a history of injury to the right knee prior to service, noting that the Veteran was cleared by the military upon service induction. During service, he was seen for right knee pain with no particular injuries. The examiner opined that the right knee condition was less likely than incurred in or caused by the claimed in-service injury, event or illness, because the evidence failed to show that his pre-existing right knee injury was aggravated beyond its normal progression during service. Similarly, the VA examiner opined that the Veteran's right carpal metacarpal (CMC) arthritis was less likely than incurred in or caused by the claimed in-service injury, event or illness. The "less likely as not" standard (less than 50 percent probability) is far from the kind of unconditional evidence required to satisfy the clear-and-unmistakable evidence standard. See Vanerson, 12 Vet. App. at 263 (Nebeker, C.J., concurring in part and dissenting in part) ("[O]nly an inference that is iron clad and copper riveted can be 'unmistakable.'"). As such, remand is required for a VA examination and clarifying opinion. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 3. Entitlement to an initial compensable rating for a left ankle disability is remanded. The Veteran seeks a compensable disability rating for his left ankle disability. The final sentence of 38 C.F.R. § 4.59 requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing, and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). In this case, a review of the claims file reveals that the prior VA left ankle examination in January 2015, did not fully comport with the requirements of Correia and therefore is inadequate for rating purposes. Thus, at present, none of the medical evidence of record may fully satisfy the requirements of Correia and 38 C.F.R. § 4.59. Accordingly, a new VA examination is necessary. Additionally, during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). When again adjudicating the Veteran's claim it should do so under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021, with the criteria that is more favorable to the Veteran being applied. See Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Finally, any outstanding VA and private treatment records should also be obtained and associated with the record. See 38 U.S.C. § 5103A(b). The matters are REMANDED for the following action: 1. Request the Veteran to identify all medical providers (VA and private) from whom he has received treatment for the left ankle disability, right knee disability and right wrist disability, and complete and return an appropriate authorization form for each treatment provider identified (if any). After obtaining the completed release forms, request all identified pertinent medical records (if any). If possible, the Veteran should get these records and submit them himself to expedite the case (if any). 2. Schedule the Veteran for an examination by an appropriate clinician to determine whether the Veteran's right knee disability and right ankle disability is etiologically related to service. After reviewing the entire claims file, the examiner must opine as to the following: (a) Is there clear and unmistakable (obvious and manifest) evidence demonstrating that the Veteran's right knee disability and/or right ankle disability existed prior to his entry into active duty? Please explain why or why not. (b) If the answer to (a) is "Yes," is there clear and unmistakable (obvious and manifest) evidence demonstrating that the Veteran's right knee disability and/or right ankle disability was not aggravated (i.e., the underlying disability was not increased in severity) beyond their normal progression during his period of active duty? Please explain why or why not. (c) If there is no clear and unmistakable evidence that a current right knee disability and/or right ankle disability pre-existed service, then the examiner is asked whether it is at least as likely as not (50 percent probability or greater) that the disorder is directly related to service. Please explain why or why not. The examiner should consider all evidence, including lay statements regarding onset and continuity of symptoms, and must provide a complete rationale for all opinions expressed. 3. Schedule the Veteran for a VA examination to assess the current severity of his service-connected left ankle disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. (Continued on the next page) All indicated tests and studies must be conducted, specifically, the Veteran's range of motion on both active and passive motion and in weight-bearing and nonweight-bearing. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any incapacitating episodes and/or flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). John J. Crowley Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Azizi, T. 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.