Citation Nr: 21041092 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 14-07 192A DATE: July 8, 2021 ORDER A rating in excess of 10 percent for right knee chondromalacia is denied. A rating in excess of 10 percent for left knee Palligrini-Stieda's disease with chondromalacia is denied. A rating in excess of 10 percent for seborrheic dermatitis is denied. A rating in excess of 10 percent for bilateral pes planus is denied. Service connection for a right shoulder disability is denied. Service connection for a left shoulder disability is denied. Service connection for a right elbow disability is denied. Service connection for a left elbow disability is denied. Service connection for a bilateral hearing loss disability is denied. Service connection for residuals of a traumatic brain injury (TBI) (claimed head injury) is denied. Service connection for a neck or cervical spine disability is denied. Service connection for a low back or thoracolumbar spine disability, claimed secondary to the service-connected right and left knee disabilities is denied. A total disability rating based on individual unemployability (TDIU) due to service-connected disability is denied. FINDINGS OF FACT 1. Throughout the pendency of the appeal, the Veteran had full extension of the right knee and flexion at most limited to 115 degrees. 2. Throughout the pendency of the appeal, the Veteran had full extension of the left knee and flexion at most limited to 120 degrees. 3. The Veteran's seborrheic dermatitis affects none (0 percent) of the total body area and none (0 percent) of the exposed area. 4. The Veteran's bilateral pes planus is manifested by moderate symptoms of tenderness to the arches, pain accentuated on use and decreased longitudinal arch height on weight-bearing, bilaterally. 5. The Veteran's right shoulder disability did not have its clinical onset due to disease or injury sustained during his period of service and right shoulder osteoarthritis was not manifested within one year of separation from service. 6. The Veteran's left shoulder disability did not have its clinical onset due to disease or injury sustained during his period of service and left shoulder osteoarthritis was not manifested within one year of separation from service. 7. A right elbow disability is not attributable to disease or injury sustained during the Veteran's period of service. 8. A left elbow disability is not attributable to disease or injury sustained during the Veteran's period of service. 9. A bilateral hearing loss disability is not attributable to acoustic trauma sustained during the Veteran's period of service. 10. Residuals of a TBI are not attributable to disease or injury sustained during the Veteran's period of service. 11. The Veteran's neck or cervical spine disability did not have its clinical onset due to disease or injury sustained during his period of service and was not manifested within one year of separation from service. 12. The Veteran's low back or thoracolumbar spine disability did not have its clinical onset due to disease or injury sustained during his period of service and was not manifested within one year of separation from service. The Veteran's low back or thoracolumbar spine disability was not caused by or made worse by his service-connected right or left knee disabilities. 13. The service-connected disabilities are not shown to preclude the Veteran from securing and following substantially gainful employment consistent with his work and education background. CONCLUSIONS OF LAW 1. The criteria for a rating in excess of 10 percent for right knee chondromalacia are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71(a), Diagnostic Code (DC) 5260. 2. The criteria for a rating in excess of 10 percent for left knee Palligrini-Stieda's disease with chondromalacia are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71(a), DC 5260. 3. The criteria for a rating in excess of 10 percent for seborrheic dermatitis are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.118, DC 7806. 4. The criteria for a rating in excess of 10 percent for bilateral pes planus are not met. 38 U.S.C. § 1155 (2012); 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.71a, DC 5276. 5. The criteria for entitlement to service connection for a right shoulder disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 6. The criteria for entitlement to service connection for a left shoulder disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 7. The criteria for entitlement to service connection for a right elbow disability are not met. 38 U.S.C. §§ 1110, 1154; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for entitlement to service connection for a left elbow disability are not met. 38 U.S.C. §§ 1110, 1154; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for entitlement to service connection for a bilateral hearing loss disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.385. 10. The criteria for entitlement to service connection for residuals of a TBI are not met. 38 U.S.C. §§ 1110, 1154; 38 C.F.R. §§ 3.102, 3.303. 11. The criteria for entitlement to service connection for a neck or cervical spine disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. 12. The criteria for entitlement to service connection for a low back or thoracolumbar spine disability are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. 13. The criteria for assignment of a TDIU are not met. 38 U.S.C. §§ 1155, 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.340, 3.341, 4.16, 4.18, 4.19. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1988 to August 1991. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from a March 2011 rating decision issued by the RO. In February 2015, the Veteran and his spouse testified in a hearing at the RO (Travel Board hearing) before the undersigned Veterans Law Judge. A transcript is of record The Board remanded the appeal in June 2016 for additional development. In pertinent part, the Board instructed the RO to schedule the Veteran for VA examination to ascertain the nature and etiology of the claimed shoulder, elbow, TBI, hearing loss, cervical spine (neck) and lumbar spine (low back) disabilities and the level of severity of his service-connected left and right and knee, dermatitis and bilateral pes planus disabilities. The Veteran received VA examinations and/or VA examiners offered medical opinions in November 2018, February 2019, September 2020, October 2020, November 2020 and January 2021 addressing the nature and etiology of the claimed shoulder, elbow, TBI, hearing loss, cervical spine (neck) and lumbar spine (low back) disabilities and the severity of his service-connected left and right and knee, dermatitis and bilateral pes planus disabilities. The development has been completed and the case has been returned to the Board for appellate consideration. Increased Rating Disability ratings are determined by application of the criteria set forth in VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. The Veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). "Staged" ratings are appropriate for any rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007); Fenderson v. West, 12 Vet. App. 119 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. 1. Entitlement to a rating in excess of 10 percent for right knee chondromalacia 2. Entitlement to a rating in excess of 10 percent for left knee Palligrini-Stieda's disease with chondromalacia The ratings for the Veteran's left and right knee disabilities have been assigned pursuant to DC 5260. Under DC 5260, a 10 percent rating is assigned for limitation of flexion to 45 degrees. A 20 percent rating contemplates limitation of flexion to 30 degrees. A rating of 30 percent requires limitation of flexion to 15 degrees. 38 C.F.R. § § 4.71a, DC 5260. The VA General Counsel has held that separate ratings under 38 C.F.R. § § 4.71a, DC 5260 (limitation of flexion of the leg) and DC 5261 (limitation of extension of the leg) may be assigned for disability of the same joint. See VAOPGCPREC 9-2004; 69 Fed. Reg. 59,990 (2004). Under DC 5261, a rating of 10 percent requires limitation of extension to 10 degrees. A rating of 20 percent requires limitation of extension to 15 degrees. A rating of 30 percent requires limitation of extension to 20 degrees. A rating of 40 percent requires limitation of extension to 30 degrees, and a rating of 50 percent requires limitation of extension to 45 degrees. 38 C.F.R. § § 4.71a, DC 5261. Separate evaluations may also be assigned for subluxation or lateral instability. See 38 C.F.R. § § 4.71a, DC 5257. Words such as 'severe,' 'moderate,' and 'mild' are not defined in the Rating Schedule. Rather than applying a mechanical formula, VA must evaluate all evidence, to the end that decisions will be equitable and just. 38 C.F.R. § § 4.6. Although the use of similar terminology by medical professionals should be considered, is not dispositive of an issue. Instead, all evidence must be evaluated in arriving at a decision regarding a request for an increased disability rating. 38 U.S.C. § 7104 (2012); 38 C.F.R. § §§ 4.2, 4.6. When evaluating disabilities of the musculoskeletal system, 38 C.F.R. § 4.40 allows for consideration of functional loss due to pain and weakness causing additional disability beyond that reflected on range of motion measurements. DeLuca v. Brown, 8 Vet. App. 202, 206-07 (1995). Further, 38 C.F.R. § 4.45 provides that consideration also be given to weakened movement, excess fatigability, and incoordination. The Board notes that, effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). VA's General Counsel has held that where a law or regulation changes during the pendency of a claim for a higher rating, the Board must first determine whether the revised version is more favorable to the veteran. In so doing, it may be necessary for the Board to apply both the old and new versions of the regulation. If the revised version of the regulation is more favorable, the retroactive reach of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. The Board must generally apply both the former and the revised versions of the regulation for the period prior and after the regulatory change, but an effective date based on the revised criteria may be no earlier than the date of the change. VA thus must consider the claim for a higher rating pursuant to the former and revised regulations since February 7, 2021. See VAOPGCPREC 3 2000, 65 Fed. Reg. 33,422 (2000); DeSousa v. Gober, 10 Vet. App. 461, 467 (1997). Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021, and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Under the revised criteria, effective February 7, 2021, there is no change in the criteria for evaluating limitation of flexion and/or limitation of extension under DC 5260 and 5261. However under the revised criteria, DC 5257 for recurrent subluxation and instability now provides a 30 percent rating for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation or a sprain incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribes a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation. A 20 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribes either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. For patellar instability under the revised DC 5257, a 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: A brace, cane, or walker. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. The August 2010 VA examination report reflects the Veteran's complaint of bilateral knee pain (10 on the pain scale) with associated popping, weakness, stiffness, lack of endurance, swelling, heat and redness. He denied having instability, locking, effusion, dislocation, or subluxation. He denied experiencing flares of knee pain. He used Naprosyn for pain relief. He did not use a brace or a cane and denied undergoing surgery to the knees. He denied having any history of inflammatory arthritis and was uncertain if he had osteoarthritis. He reported that he could not walk distances greater than 100 yards; engage in sports; perform heavy lifting; or, walk or stand for extended periods of time. did not report flare-ups of the knee and/or lower leg and did not report having any functional loss or functional impairment of the knees. Objectively, there was no obvious warmth, redness, swelling, or deformity. He had no crepitus with repetitive range of motion. He had full extension of the left and knees and flexion of the left knee limited to 120 degrees with increasing pain at 120 degree; flexion of the right knee was limited to 115 degrees with increasing pain. Though he had full extension of the knees, he had a slight increase in pain to his bilateral knees. There was no evidence of instability. The increase in pain of the knees on flexion and extension did not result in additional decrease in range of motion of the knees on repetitive use. He had mild fatigue, weakness, lack of endurance, and incoordination with repetitive testing of his bilateral knees. An August 2012 VA treatment record documents that on physical examination, the Veteran had crepitant knees bilaterally. The February 2019 VA knee and lower leg conditions examination report reflects the Veteran's complaint that his knees hurt. He reported that when he stood up or sat down, he was in pain; but he denied flare-ups of the knees. Objectively, he demonstrated full extension of the knees and flexion limited to 120 degrees, bilaterally. Pain was not noted on examination; there was no evidence of pain with weight bearing; and there was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no objective evidence of crepitus in the right knee but there was objective evidence of crepitus in the left knee. The Veteran was able to perform repetitive-use testing without additional loss of function or limitation in motion. The Veteran was not examined immediately after repetitive use over time or during a flare-up and the examiner was unable to determine if pain, weakness, fatigue, or incoordination significantly limited functional ability with repeated use over time or during a flare-up without resort to speculation. The examiner explained that it was not possible to estimate loss of range of motion because there was no conceptual or empirical basis for making such a determination without directly observing function under those conditions. Muscle strength testing was normal and there was no evidence of muscle atrophy. There was no right or left knee ankylosis and there was no right or left knee joint instability. The Veteran had no meniscal condition and the Veteran had no recurrent patellar dislocation, shin splints, fractures, chronic exertional compartment syndrome or any other tibial or fibular impairment. He did not use any assistive device. The examiner indicated that the Veteran's right and left knee disabilities impacted his ability to work and the Veteran reported that he had lost a week of work time in the last year and that when he stood up or sat down he was in pain. The examiner remarked that there was no evidence of pain on passive range of motion testing or non-weight bearing testing of the right and left knees. In the January 2021 medical opinion, the Director of Compensation and Pension Service (Director) documented extensive review of the claims file. The Director opined that it was at least as likely as not that there was no additional loss of range of motion of the Veteran's right and left knees during flare ups and following repeated use over time based on the evidence of record compared with knee ranges of motion in the February 2019 examination. Thus, the Director concluded there was no clinical indication to provide an estimation of additional loss of range of motion of the knees during flare ups and following repeated use over time. The Director explained that the estimation of range of motion of the Veteran's right and left knees during flare up and following repeated use over time was clinically supported by the evidence of record documented in the February 2019 examination report which showed the Veteran was able to perform repetitive use testing without additional loss of function or range of motion. Further, the Director noted that the February 2019 examination showed pain, weakness, fatigability and incoordination did not significantly limit functional ability with repeated use over a period; there was no objective evidence of pain on passive range of motion testing; and, there was no objective evidence of pain when the right and left knee joints were used in non-weight bearing. Based on the review of the claims file, the Director concluded that there was no clinical objective evidence to support a claim that the Veteran's right and left knees had additional loss of range of motion during flare ups and following repeated use over time beyond the right and left knee ranges of motion documented in the February 2019 examination report. The Director reiterated that although the Veteran contends that his bilateral knee disability had increased in severity since 2010, the evidence of record does not support objective clinical evidence of limitation in range of motion of either knee beyond results documented in the February 2019 examination report. The Veteran demonstrated full extension and flexion of the right knee limited to 115 degrees (August 2010) and 120 degrees (February 2019); he had full extension and flexion of the left knee limited to 120 degrees (August 2010 and February 2019). The August 2010 VA examination report documents that the Veteran had mild fatigue, weakness, lack of endurance, and incoordination with repetitive testing of his bilateral knees and increase in pain of the knees on flexion and extension that did not result in additional decrease in range of motion of the knees on repetitive use. The February 2019 VA examination report documents that the Veteran full extension of the knees and flexion limited to 120 degrees, bilaterally. Pain was not noted on examination; there was no evidence of pain with weight bearing; and there was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. There was no objective evidence of crepitus in the right knee but there was objective evidence of crepitus in the left knee. The Veteran was able to perform repetitive-use testing without additional loss of function or limitation in motion. The Veteran was not examined immediately after repetitive use over time or during a flare-up and the examiner was unable to determine if pain, weakness, fatigue, or incoordination significantly limited functional ability with repeated use over time or during a flare-up without resort to speculation. In January 2021, the Director found there was no clinical indication to provide an estimation of additional loss of range of motion of the knees during flare ups and following repeated use over time. The Director explained that the estimation of range of motion of the Veteran's right and left knees during flare up and following repeated use over time was clinically supported by the evidence of record documented in the February 2019 examination report which showed the Veteran was able to perform repetitive use testing without additional loss of function or range of motion. Further, the Director noted that the February 2019 examination showed pain, weakness, fatigability and incoordination did not significantly limit functional ability with repeated use over a period; there was no objective evidence of pain on passive range of motion testing; and, there was no objective evidence of pain when the right and left knee joints were used in non-weight bearing. The Director concluded that there was no clinical objective evidence to support a claim that the Veteran's right and left knees had additional loss of range of motion during flare ups and following repeated use over time and reiterated that although the Veteran contends that his bilateral knee disability had increased in severity since 2010, the evidence of record does not support objective clinical evidence of limitation in range of motion of either knee beyond results documented in the February 2019 examination report. Even considering the complaints of pain, documented above, there is no evidence of flexion of the left or right knees limited to 30 degrees. Further, the Veteran has demonstrated full extension of the knees throughout the appeal period. Thus, the preponderance of the evidence is against assignment of ratings in excess of 10 percent for right knee chondromalacia and left knee Palligrini-Stieda's disease with chondromalacia. Ankylosis, instability, meniscal impairment or tibia or fibular impairment is not demonstrated; therefore, ratings in excess of 10 percent under Diagnostic Codes 5256, 5257, 5258 and 5262 are not warranted either. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 69-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). 3. Entitlement to a rating in excess of 10 percent for seborrheic dermatitis The Veteran's seborrheic dermatitis is evaluated under 38 C.F.R. § 4.118, DC 7806. A 10 percent rating contemplates at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immuno-suppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly, during the past 12-month period. A 60 percent rating contemplates more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near-constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12-month period. The August 2010 VA examination reflects the Veteran's report of a continuous rash on his chest and shoulders. He complained itching and redness associated with his rash but denied any other symptoms. He denied using any current treatment other than over-the-counter medications. On physical examination, there was no obvious dermatitis on the chest wall. On the shoulders, there were excoriations (secondary to scratching) that were hyperpigmented but no active dermatitis. The February 2019 VA skin diseases examination report reflects that the Veteran used Listerine, ice, and hydrogen peroxide to treat his seborrheic dermatitis when it itched, and those treatments provided some relief. Otherwise he had not been prescribed any medication or undergone any treatments or procedures other than systemic or topical medications in the past year for treatment of his skin disease. On physical examination, the Veteran's seborrheic dermatitis affected none of his total body area and none of his exposed area. The examiner indicated that the Veteran had a current skin condition without any visible characteristic lesions at the time of examination and reported that there were no visible signs/symptoms of seborrheic dermatitis on examination. The Veteran's seborrheic dermatitis did not cause scarring or disfigurement of the head, face or neck and there were no physical findings, complications, conditions, signs and/or symptoms related to his seborrheic dermatitis. Here, there are no visible signs/symptoms of the Veteran's seborrheic dermatitis and he has not been prescribed any medication or undergone any treatments or procedures for treatment of his skin disease. At most he used Listerine, ice, and hydrogen peroxide to treat his seborrheic dermatitis when it itched and that provided some relief of his symptoms. As the Veteran's seborrheic dermatitis affected none of his total body area and none of his exposed area, the preponderance of the evidence is against assignment of a rating in excess of 10 percent. As the seborrheic dermatitis has not caused scarring or disfigurement of the head face or neck, a rating in excess of 10 percent is not warranted under other diagnostic criteria. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. at 369-70 (2017). 4. Entitlement to a rating in excess of 10 percent for bilateral pes planus The rating for the Veteran's bilateral pes planus has been assigned pursuant to DC 5276. Under DC 5276, a 10 percent rating is assigned for moderate acquired flatfoot with weight bearing line over or medial to the great toe, inward bowing of the tendo Achillis, and pain on manipulation and use of the feet, bilateral or unilateral. A 30 percent rating is assigned for bilateral severe acquired flatfoot with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use and characteristic callosities. A 50 percent rating is assigned for pronounced acquired flatfoot with marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo Achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 5276. To reiterate, the Rating Schedule does not define nonspecific words such as "moderate" or "severe." Rather than applying a mechanical formula, the Board must evaluate all the evidence to ensure its decision is "equitable and just." See 38 C.F.R. § 4.6. The Board notes that, effective February 7, 2021, VA revised the criteria for evaluating musculoskeletal disorders. See Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries, 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020); Correction, 86 Fed. Reg. 8142, 8143 (Feb. 4, 2021) (changing new diagnostic code applicable to plantar fasciitis from 5285 to 5269). Under the revised criteria, effective February 7, 2021, there is no change in the criteria for evaluating pes planus under DC 5276. The August 2010 VA examination report reflects the Veteran's complaint of pain to the plantar surface of his feet. He reported his bilateral foot pain was a 10 on the pain scale. He also complained of weakness, stiffness, swelling and fatigability but denied heat, redness, and lack of endurance. He noted there was no differencing his feet pain from standing, walking, or sitting. He complained his feet always hurt. He did not use brace, cane corrective shoes or inserts. He could not stand or walk for prolonged periods of time and was unable to engage in any sports which required running. Objectively, he had pes planus that was accentuated upon standing. There was no medial deviation of the Achilles. He demonstrated tenderness to the arch of his feet bilaterally. There was no evidence of use of inserts within his shoes and he had no abnormal shoe wear. Dorsalis pedis and posterior tibial pulses were 2/2. There was no lower extremity edema, tremor, muscular fasciculation, or atrophy noted in his extremities. Patellar and Achilles tendon reflexes were 1/1. The Veteran walked with a mild limp without the use of an assistive device. The February 2019 VA foot conditions examination report reflects the Veteran's complaint that he was flat footed, and his feet hurt. The examiner documented that the Veteran had pain on use of his feet that was accentuated on use of the feet. There was no pain on manipulation of the feet; no indication of swelling on use; and, no characteristic calluses. The Veteran did not have extreme tenderness of the plantar surfaces of his feet, but he did have decreased longitudinal arch height on weight-bearing of both feet. There was no objective evidence of marked deformity (i.e., pronation, abduction, etc.) and he did not have marked pronation of one or both feet. The weight-bearing line did not fall over or medial to the great toe and there was no lower extremity deformity, other than pes planus, causing alteration of the weight bearing line. He did not have inward bowing of the Achilles Tendon and did not have marked inward displacement and severe spasm of the Achilles Tendon. He did not have Morton's Neuroma and metatarsalgia; hammer toe; hallux valgus; hallux rigidus; or, acquired pes cavus. There was no evidence of malunion or nonunion of tarsal or metatarsal bones and the Veteran did not have any other foot injuries or foot conditions. Though the Veteran had pain on use of his feet that was accentuated on use of the feet, he did not have pain on manipulation of the feet; indication of swelling on use; or, characteristic calluses. There was no extreme tenderness of the plantar surfaces of his feet or objective evidence of marked deformity (i.e., pronation, abduction, etc.) and he did not have marked pronation of one or both feet. He did not have inward bowing of the Achilles Tendon and did not have marked inward displacement and severe spasm of the Achilles Tendon. In short, the constellation of his symptoms was not productive of a disability picture approximating "severe" bilateral pes planus. Thus, the preponderance of the evidence is against assignment of a rating in excess of 10 percent for bilateral pes planus. Acquired pes cavus, malunion or nonunion of tarsal or metatarsal bones, and other foot injuries or foot conditions are not demonstrated; therefore, a rating in excess of 10 percent under Diagnostic Codes 5278, 5283 and 5284 are not warranted either. The Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. at 369-70 (2017). Service Connection Service connection will be established if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of incurrence or aggravation of a disease or injury in service; and (3) evidence of a relationship between the claimed disease or injury in service and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir.2004); Caluza v. Brown, 7 Vet. App. 498 (1995); 38 C.F.R. § 3.303. In addition, for Veterans who have served 90 days or more of active service during a period of war or after December 31, 1946, certain chronic disabilities, including arthritis, and sensorineural hearing loss 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, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. §§ 3.303 (b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Arthritis, and sensorineural hearing loss are chronic diseases and presumptive service connection must be considered. 38 U.S.C. § 1101; 38 C.F.R. § 3.303(b). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection is also warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b). 5. Entitlement to service connection for a right shoulder disability 6. Entitlement to service connection for a left shoulder disability The Veteran contends that he has current right and left shoulder disabilities that developed due to injury sustained during service. March 1990 service treatment records document that the Veteran fell on his left arm and hurt his left shoulder. Objectively, he had full range of motion of the left shoulder with discomfort. X-ray findings were normal. The diagnosis was shoulder sprain. The service treatment records contain no complaints of, treatment for or diagnoses of a right shoulder disability. After service, September 2011 MRI findings of the right shoulder were consistent with a full thickness rotator cuff tear with secondary abnormalities. The February 2019 VA shoulder and arm conditions examination report documents diagnoses of right and left shoulder impingement syndrome and acromioclavicular (AC) joint osteoarthritis. The Veteran reported that he sustained right and left shoulder injuries during Aero Assault School. The examiner opined that the right shoulder disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that the Veteran had no right shoulder disorder during his period of service and noted that after service the Veteran received treatment for complaints of right shoulder pain in 2003 and 2011. The examiner concluded there was no evidence of chronicity of care and therefore no nexus was established. The examiner also opined that the left shoulder disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained the in-service left shoulder injury was acute and noted radiographic studies showed no abnormalities. The examiner concluded there was no evidence of chronicity of care and determined a nexus could not be established. Though the Veteran has current right and left shoulder disabilities, the Board finds that the preponderance of the evidence is against a finding of any relationship between the onset of the disabilities and a period of service. Rather, the February 2019 VA examination found that the Veteran's right shoulder disability had its clinical onset after service in approximately 2003 (and 2011), approximately 12 years after his discharge from service. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service resulting in any chronic or persistent disability). As for the left shoulder disability, the February 2019 VA examination found that the in-service left shoulder injury was acute and did not lead to the current disability. The examiner explained that there was no evidence of chronicity of care for either right or left shoulder disabilities and determined nexus could not be established. This conclusion is probative as it is based on facts presented by both the service treatment records and the assertions made by the Veteran at the time of the VA examination. There is also no competent or credible evidence or opinion that suggests that there exists a medical relationship, or nexus, between any current right or left shoulder disabilities and a period of the Veteran's service. In addition, there is no evidence of right or left shoulder arthritis in service. To determine that a chronic disease was shown in service, the disease identity must be established. 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1339. No examiner in service, or since, has established chronicity or an underlying chronic disease process in service. In sum, characteristic manifestations sufficient to identify the disease (arthritis) entity were not noted. Further, there is no demonstration of continuity of symptomatology or evidence of arthritis within one year of separation from service. Thus, service connection cannot be awarded on a presumptive basis. 38 U.S.C. § 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. § 3.303(b), 3.307, 3.309. The Veteran is competent to report his symptoms, but he is not competent to link his right or left shoulder disabilities to service. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159. Lay evidence may be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition (i.e., when the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer); (2) the layperson is reporting a contemporaneous medical diagnosis, or; (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009) (where widow seeking service connection for cause of death of her husband, the Veteran, the Court holding that medical opinion not required to prove nexus between service connected mental disorder and drowning which caused Veteran's death). The Veteran is not competent to establish that his current right and left shoulder disabilities had their clinical onset due to injury sustained during a period of service. The Veteran is not competent to offer opinion as to etiology of any current right and left shoulder disabilities. The question regarding the etiology of such disabilities is a complex medical issue that cannot to be addressed by a layperson. For these reasons, his allegations are non-specific and are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claims for service connection for right and left shoulder disabilities must be denied. The preponderance of the evidence is against the claims and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 7. Entitlement to service connection for a right elbow disability 8. Entitlement to service connection for a left elbow disability The Veteran contends he sustained right and left elbow injuries in Air Assault School during service. The service treatment records reflect that the Veteran fell on his left arm and sustained injury to his left shoulder. The service treatment records contain no complaints of, treatment for or diagnoses of right or left elbow disabilities. After service, the February 2019 VA elbow and forearm conditions examination report documents normal right and left elbows (i.e., the Veteran did not have a diagnosed disability of the elbows). The Veteran reported that his elbow pain had its onset during service and continued currently. The examiner explained that the Veteran's complaints were subjective and there were no service treatment records to corroborate his statement that elbow pain had its onset during service. The examiner indicated that the elbow complaints did not impact the Veteran's ability to perform any type of occupational task. The examiner concluded no diagnosis of right or left elbow disability was warranted based on examination. The examiner opined that the claimed left and right elbow disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that there was no diagnosis of a left or right elbow condition. The examiner noted there was no mention of a left or right elbow injury in the service treatment records and concluded there was no evidence of chronicity of care or a chronic condition. The examiner reported objective examination was normal with subjective complaints only and determined that a nexus had not been established. Here, the Board finds that the preponderance of the evidence is against a finding of any relationship between the onset of the Veteran's subjective complaints of right and left elbow pain and a period of service. Rather, the February 2019 VA examination found that objective examination of the right and left elbows was normal; there was no mention of a left or right elbow injury in the service treatment records; and, there was no evidence of chronicity of care or a chronic right or left elbow condition. Thus, the examiner determined nexus could not be established. This conclusion is probative as it is based on facts presented by both the service treatment records and the assertions made by the Veteran at the time of the VA examination. There is also no competent or credible evidence or opinion that suggests that there exists a medical relationship, or nexus, between any subjective complaints of right or left shoulder pain and a period of the Veteran's service. The Veteran is competent to report his symptoms, but he is not competent to link his subjective complaints of right or left elbow pain to service. The Veteran is not competent to establish that he has current right and left elbow disabilities that onset due to injury sustained during a period of service. The Veteran is not competent to diagnose or offer opinion as to etiology of any current right and left elbow disabilities. The question regarding the etiology of such disabilities is a complex medical issue that cannot to be addressed by a layperson. For these reasons, his allegations are non-specific and are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claims for service connection for right and left elbow disabilities must be denied. The preponderance of the evidence is against the claims and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 53-56 (1990). 9. Entitlement to service connection for a bilateral hearing loss disability Impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies of 500, 1000, 2000, 3000, or 4000 Hertz is 40 decibels or greater; the thresholds for at least three of those frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. The Veteran asserts that noise exposure from small arms fire, heavy artillery, mortars, grenades, helicopters, and aircraft engines in service caused bilateral hearing loss disability. The April 1988 enlistment examination found that on audiometric testing, the pure tone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 0 5 0 LEFT 10 0 0 0 0 The April 1991 medical evaluation board (MEB) examination found that on audiometric testing, the pure tone thresholds, in decibels, were: HERTZ 500 1000 2000 3000 4000 RIGHT 5 0 0 5 10 LEFT 5 0 5 10 10 Thus, the service medical records show no complaints or findings indicative of hearing loss disability. However, the absence of in-service evidence of hearing loss disability is not fatal to a claim for service connection for hearing loss disability. Ledford v. Derwinski, 3 Vet. App. 87 (1992). Evidence of a current hearing loss disability meeting the requirements of 38 C.F.R. § 3.385 and a medically sound basis for attributing that hearing loss disability to service may serve as a basis to establish service connection for hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993). An August 2010 VA audiometric examination detected the following pure tone thresholds in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 35 35 30 35 35 LEFT 40 40 35 35 35 Speech audiometry found speech recognition ability of 92 percent in the right ear and 92 percent in the left ear. Those findings demonstrate bilateral hearing loss disability for VA purposes. The audiologist opined that given the Veteran's hearing was within normal limits at the time of the last examination in service and because there was no frequency specific testing a year after service that indicated a hearing loss had manifested to a compensable degree, the Veteran's current hearing loss was less likely as not due to noise exposure incurred during a period of military service. A November 2018 VA audiometric examination detected the following pure tone thresholds in decibels: HERTZ 500 1000 2000 3000 4000 RIGHT 20 15 15 20 30 LEFT 15 15 15 15 15 The audiologist indicated that the puretone test results were valid for rating purposes. However, the audiologist noted that the use of speech discrimination scores was not appropriate for the Veteran because of language difficulties, cognitive problems, inconsistent speech discrimination scores, etc., that make combined use of puretone average and speech discrimination scores inappropriate. audiometry found speech recognition ability of 92 percent in the right ear and 92 percent in the left ear. Those findings do not demonstrate bilateral hearing loss disability for VA purposes. Regardless, the audiologist noted there was no significant permanent shift in hearing thresholds beyond normal test variability from entrance to separation, which was objective evidence of no permanent auditor damage on active duty from conceded noise. The audiologist noted that the Veteran reported a head injury during service but there was no documentation of such in the service treatment records. The audiologist explained that although noise exposure was conceded and the relationship of noise, auditory damage and hearing loss was well established, auditory damage and hearing loss were not conceded based on noise alone. The audiologist explained there must be a nexus of auditory damage to relate current hearing loss to military noise and not another etiology and concluded the evidence was against a nexus in this case. Thus, the audiologist opined that the hearing loss was less likely as not related to military noise. In a September 2020 medical opinion, the VA audiologist opined that the claimed hearing loss was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The audiologist explained that service entrance and exist examinations showed all hearing thresholds were at 10 decibels or better which was indicative of no significant permanent shift on active duty. The audiologist reported there were no post-service audiometric records, specifically within the first year after separation, showing decrease in hearing. The audiologist concluded that although hazardous noise exposure on active duty was conceded, there was no evidence to suggest delayed onset of military noise-induced hearing loss. To the extent that the Veteran has current diagnoses of mixed hearing loss (as documented in the August 2010 VA examination report), the Board finds that the preponderance of the evidence is against a finding of a relationship between those disabilities and service. Rather, the evidence shows that it is less likely than not that any current bilateral hearing loss disability is etiologically related to acoustic trauma in service. The Board notes that a hearing loss disability was first documented many years after service. The audiologist in August 2010 explained that given the Veteran's hearing was within normal limits at the time of the last examination in service and because there was no frequency specific testing a year after service that indicated a hearing loss had manifested to a compensable degree, the Veteran's current hearing loss was less likely as not due to noise exposure incurred during a period of military service. The audiologist in November 2018 explained that although noise exposure was conceded and the relationship of noise, auditory damage and hearing loss was well established, auditory damage and hearing loss were not conceded based on noise alone; there must be a nexus of auditory damage to relate current hearing loss to military noise and not another etiology. The audiologist concluded the evidence was against a nexus in this case and opined that the hearing loss was less likely as not related to military noise. In the September 2020 opinion, the audiologist explained there was no indication of a significant permanent threshold shift on active duty and there were no post-service audiometric records within the first year after separation showing decrease in hearing. The audiologist concluded that although hazardous noise exposure on active duty was conceded, there was no evidence to suggest delayed onset of military noise-induced hearing loss. There is no competent or credible evidence or opinion that suggests that there is a medical relationship, or nexus, between any current hearing loss disability and service. The Veteran has not submitted any competent medical evidence which supports the claim. Additionally, there is no evidence of sensorineural hearing loss disability in service. To determine that a chronic disease was shown in service, the disease identity must be established. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). No examiner in service, or since, has established chronicity or an underlying chronic disease process in service. In sum, characteristic manifestations sufficient to identify the disease (other organic disease of the nervous system) entity were not noted. Further, there is no demonstration of continuity of symptomatology or evidence of sensorineural hearing loss disability within one year of separation from service. Thus, service connection cannot be awarded on a presumptive basis. 38 U.S.C. § 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. § 3.303(b), 3.307, 3.309. The Veteran is competent to state that he sustained acoustic trauma in service. However, he is a lay person and is not competent to establish that any current bilateral hearing loss disability onset because of any in-service-acoustic trauma. The Veteran is not competent to offer opinion as to etiology of any current bilateral hearing loss disability. The question regarding the etiology of that disability is a complex medical issue that cannot to be addressed by a layperson. For these reasons, his allegations are non-specific and are no more than conjecture and do not constitute competent evidence. To the extent that the Veteran alleges a continuity of symptomatology, the Board finds that is less likely as the evidence does not document any symptoms or complaints hearing loss for many years following separation from service. The claim of entitlement to service connection for bilateral hearing loss disability must be denied. The Board finds that the preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 53-56 (1990). 10. Entitlement to service connection for residuals of a TBI The Veteran asserts that he was struck on the head by a helicopter wheel during service. He was "dazed by the injury but did not have loss of consciousness (LOC)." The service treatment records contain no complaints of, treatment for or diagnoses of residuals of a head injury. After service, a January 1992 VA report of accidental injury reflects that the Veteran struck a railroad control box and telephone pole and sustained major head injuries to the skull, eye, and teeth. A January 1992 record of hospitalization documents that the Veteran had been inebriated at the time of his motor vehicle accident (MVA) and sustained laceration of the left forehead and left upper and lower eyelids. He had obvious blow-out fracture of the left orbit with zygomatic arch involvement. An April 1993 record of hospitalization reflects that the Veteran had been involved in a motor vehicle accident (MVA) in 1992. He was intoxicated and hit a telephone pole and sustained injury (i.e., smashed) to the left temporal area of his head. A June 1994 VA general medical examination report reflects, in pertinent part, medical history of head injury secondary to MVA with residual neurologic abnormality. The diagnosis was head injury with neurologic residual. A June 1994 VA diseases/injuries of the brain reflects that the Veteran had history of trauma to face following MVA 2 years earlier. He sustained fracture of the left facial bones and had numbness of the left side of the face with some areas of increased sensitivity, numbness of left side of the jaw and gum. He had poor attention, calculation, and memory. He had loss of partial cognition secondary to head injury. The diagnoses were left facial injury and posttraumatic headaches. A November 2012 VA treatment record reflects a prior medical history of history of head injury. The November 2018 VA residuals of TBI examination report documents diagnosis of TBI. The Veteran reported that he was struck on the head by a helicopter rotor/wheel during service and was "dazed" but did not suffer LOC. He also reported MVA post-discharge with head trauma. Since his discharge from service, he complained of headaches and memory impairment. The physician acknowledged the MVA occurred within a year of the Veteran's discharge but explained it was not considered service connected. The physician noted the Veteran complained of diplopia and headaches since the MVA, but this was unrelated to the incident where he hit his head as he complained of headaches since service, unrelated to the MVA head injuries. On examination, the physician acknowledged it was more likely than not that the Veteran experienced a mechanism of injury while serving in the military resulting in trauma to the head and alteration of consciousness. The physician explained though the injury was not documented in the service treatment records, it was consistent with previous reports. However, the physician reported that the Veteran had a TBI from a MVA post discharge from service that was documented and was most likely the source of his sequalae of deficits documented in the evaluation such as decreased concentration and memory. The physician explained that the Veteran reported that his headaches preceded both head injuries and were not felt to be related to either TBI. Additionally, the Veteran had overlapping symptoms such as moodiness and lack of motivation that could not be differentiated between the TBI and psychiatric disorder. Finally, the diplopia was related to the TBI from the MVA and was not considered service connected. The physician concluded that it was more likely than not that the Veteran sustained a mild TBI during service but there was no disability or residuals from this injury. However, after service he sustained another TBI which was more likely than not the source of his current residuals. In a November 2020 medical opinion, the neurologist noted that the Veteran reported that he sustained a minor TBI from a helicopter wheel that struck his head in 2011 (almost 10 years after his separation from service). The Veteran reported that he was dazed but did not suffer LOC. The neurologist also noted that the Veteran sustained TBI from MVA after service in 1992. The neurologist explained that the post service MVA caused skull fracture suggestive of significant TBI. The neurologist determined that there was lack of evidence in the service treatment records of any TBI or TBI related migraine headaches or any symptoms of post-concussion syndrome in the service treatment records. The neurologist opined that the Veteran's TBI symptoms, including moodiness and lack of motivation, were less likely than not due to a TBI the Veteran reports to have sustained in service before 1991. The neurologist explained that opinion was based on a lack of any evidence of a TBI event during service combined with the Veteran waiting 10 years after separation from service to report the in-service TBI with consideration of the major TBI the Veteran sustained in a MVA in 1992 after service. Though the Veteran has current residuals of TBI, the Board finds that the preponderance of the evidence is against a finding of any relationship between the onset of the current disability and a claimed TBI sustained during a period of service. Rather, the November 2018 VA examination found that though the Veteran sustained a mild TBI during service, there was no disability or residuals from this injury. However, after service he sustained another TBI which was more likely than not the source of his current residuals. In the November 2020 medical opinion, citing a lack of any evidence of a TBI event during service combined with the Veteran waiting 10 years after separation from service to report the in-service TBI with consideration of the major TBI the Veteran sustained in a MVA in 1992 after service, the neurologist opined that the Veteran's TBI symptoms were less likely than not due to a TBI the Veteran reports to have sustained in service before 1991. This conclusion is probative as it is based on facts presented by both the service treatment records and the assertions made by the Veteran at the time of the VA examination. There is also no competent or credible evidence or opinion that suggests that there exists a medical relationship, or nexus, between any current residuals of TBI and the claimed TBI suffered during a period of service from a helicopter wheel striking him against his head. The Veteran is competent to report his residual symptoms, but he is not competent to link his TBI residual disability to service. The Veteran is not competent to establish that he has residuals of a TBI that onset due to TBI sustained during a period of service. The Veteran is not competent to offer opinion as to etiology of any current residuals of a TBI. The question regarding the etiology of such disabilities is a complex medical issue that cannot to be addressed by a layperson. For these reasons, his allegations are non-specific and are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claim for service connection for residuals of a TBI must be denied. The preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 53-56 (1990). 11. Entitlement to service connection for a neck or cervical spine disability The Veteran contends that he has a current neck or cervical spine disability that developed due to injury sustained during service. The service treatment records contain no complaints of, treatment for or diagnoses of a neck or cervical spine disability. After service, a September 2011 treatment record documents assessment, in pertinent part, of degenerative spondylosis of the cervical spine. A December 2012 VA treatment record reflects the Veteran's complaint, in pertinent part, of neck pain. The February 2019 VA neck (cervical spine) conditions examination report documents diagnosis of normal cervical spine. The Veteran reported that his neck did not turn as it previously had (i.e., he had limitation of motion of his neck). The examiner concluded that any minor abnormalities on examination did not warrant diagnosis of a cervical spine disability. The examiner opined that the neck or cervical spine disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that there was no documentation of a neck disorder in the service treatment records and concluded there was no evidence of chronicity of care and therefore no nexus was established. In an October 2020 VA medical opinion, the examiner noted that the Veteran received treatment for a 4-day history of low back pain in April 1990 during service. The examiner concluded, in pertinent part, that the in-service back treatment in April 1990 was less likely than not the nexus for the current neck complaints/condition. The examiner explained the in-service disorder in April 1990 was acute and self-limited. The examiner also noted the Veteran sustained a fall during service in May 1991, but the Veteran's current neck disorder was less likely than nor related to that event. The examiner noted that cervicalgia was first documented in 2017 and more likely than not onset between 2010 and 2017. The examiner concluded, in pertinent part, that it was less likely than not that the Veteran's neck condition had its nexus in service due to events or injury incurred in April 1990 or May 1991. Though the Veteran has a current neck or cervical spine disability, the Board finds that the preponderance of the evidence is against a finding of any relationship between the onset of the disability and a period of service. Rather, the February 2019 VA examination found that the Veteran's cervical spine disability was less likely than not incurred in or caused by the claimed in-service injury, event or illness because there was no documentation of a neck disorder in the service treatment records and no evidence of chronicity of care. Simply stated, no nexus was established. The October 2020 medical opinion found that the Veteran's cervical spine disability onset sometime between 2010 and 2017, approximately 19 to 26 years after his discharge from service. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether an injury or a disease was incurred in service resulting in any chronic or persistent disability). The examiner concluded, in pertinent part, that it was less likely than not that the Veteran's neck condition had its nexus in service due to events or injury incurred in April 1990 or May 1991. This conclusion is probative as it is based on facts presented by both the service treatment records and the assertions made by the Veteran at the time of the VA examination. There is also no competent or credible evidence or opinion that suggests that there exists a medical relationship, or nexus, between any current neck or cervical spine disability and a period of the Veteran's service. In addition, there is no evidence of degenerative spondylosis (or arthritis) in service. To determine that a chronic disease was shown in service, the disease identity must be established. 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1339. No examiner in service, or since, has established chronicity or an underlying chronic disease process in service. In sum, characteristic manifestations sufficient to identify the disease (arthritis) entity were not noted. Further, there is no demonstration of continuity of symptomatology or evidence of arthritis within one year of separation from service. Thus, service connection cannot be awarded on a presumptive basis. 38 U.S.C. § 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. § 3.303(b), 3.307, 3.309. The Veteran is competent to report his symptoms, but he is not competent to link his cervical spine disability to service. The Veteran is not competent to establish that he has a neck or cervical spine disability that onset due to injury sustained during a period of service. The Veteran is not competent to offer opinion as to etiology of any current neck or cervical spine disability. The question regarding the etiology of such disability is a complex medical issue that cannot to be addressed by a layperson. For these reasons, his allegations are non-specific and are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claim for service connection for a neck or cervical spine disability must be denied. The preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 53-56 (1990). 12. Entitlement to service connection for a low back or thoracolumbar spine disability The Veteran contends that his current low back or thoracolumbar spine disability developed due to injury sustained during service or was caused or aggravated by his service-connected right and left knee disabilities. An April 1990 service treatment records reflects the Veteran's complaint of a 4-day history of back pain. Objectively, he had full range of motion of the back with discomfort. The assessment was low back pain. A May 1991 service treatment record reflects that examination of the spine was normal. After service, a June 1994 VA general medical examination report documents the Veteran's complaint of a history of low back pain and that he experienced low back pain with walking and prolonged standing. On examination, the diagnosis, in pertinent part, was low back pain. A September 2010 VA spine examination report documents diagnoses of mild diffuse osteopenia, mild lumbar instability, minimal degenerative disc, and spondylosis from L3 through S1 and mild degenerative facet joints, T12 and L1 and L4 through S1. The Veteran reported that his low back pain onset during military service in 1991 and he continued to experience low back pain. He also reported that his service-connected bilateral knee disabilities caused his back condition. On examination, the examiner opined that the Veteran's current low back condition was less likely than not caused by or secondary to his service-connected bilateral knee disability. The examiner explained there was no indication that any traumatic condition of the bilateral knees would impact the Veteran's gait and posture to affect the lumbar spine. September 2011 x-ray findings showed degenerative disc disease and spondylolisthesis at L4-5. September 2011 treatment record documents assessment, in pertinent part, of degenerative spondylosis of the lumbar spine. A February 2019 VA back (thoracolumbar spine) conditions examination report documents diagnoses of degenerative arthritis of the spine and spondylolisthesis. The Veteran reported that his low back pain onset during his period of military service. On examination the examiner opined that the low back disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained the Veteran had no diagnosis of a low back disability during service and no complaints of a low back disability on discharge from service. The examiner concluded there was no evidence to suggest that the Veteran's low back disability had onset during service as there was no objective evidence of chronicity of care. The examiner concluded there was no nexus. The examiner also opined that the low back disability was less likely than not proximately due to or the result of the Veteran's service-connected bilateral knee disabilities. The examiner explained that the two conditions were not medically related as the low back disability was a separate entity entirely from the service-connected left and right knee disabilities. The examiner explained degenerative changes in the spine were due to age and everyone experienced some disc degeneration after age 40. Thus, the examiner concluded a nexus had not been established. Further, the examiner opined that the Veteran's low back disability was less likely as not aggravated beyond its natural progression by the service-connected right and left knee disabilities. The examiner explained there was no evidence to suggest the Veteran's degenerative arthritis of the lumbar spine had anything to do with the service-connected left and right knee disabilities. In an October 2020 medical opinion, the examiner opined that the Veteran's low back disability less likely onset due to injury sustained in service. The examiner noted that the Veteran complained of a 4-day history of low back pain in April 1990 but concluded it was less likely than not that there was a nexus relationship between that in-service complaint and the Veteran's current low back disability. The examiner explained that the in-service complaints in April 1990 were acute and self-limited. The examiner also noted the Veteran sustained a fall in May 1991. Noting that the next documented record of treatment for a back disability was September 2010, the examiner determined that the Veteran's current low back disability more likely onset in approximately 2010. The examiner concluded that it was less likely than not that the Veteran's back disability had nexus relationship to service, including injury in April 1990 and May 1991. Though the Veteran has a current low back or thoracolumbar spine disability, the Board finds that the preponderance of the evidence is against a finding of any relationship between the onset of the disability and a period of service or a service-connected disability. Rather, the February 2019 VA examination found that that the low back disability was less likely than not proximately due to or the result of the Veteran's service-connected bilateral knee disabilities because the two conditions were not medically related and were separate entities. The examiner explained that the degenerative changes in the spine were due to age. Thus, the examiner concluded a nexus had not been established. Further, the examination found that the Veteran's low back disability was less likely as not aggravated beyond its natural progression by the service-connected right and left knee disabilities given that there was no evidence to suggest the Veteran's degenerative arthritis of the lumbar spine had anything to do with the service-connected left and right knee disabilities. The October 2020 medical opinion found that the Veteran's current low back or thoracolumbar spine disability onset in approximately 2010, approximately 19 years after his discharge from service. See Maxon v. Gober, 230 F.3d at 1333 (Fed. Cir. 2000). The examiner concluded, in pertinent part, that the onset of the Veteran's current low back disability was less likely than not due to events or injury incurred in April 1990 or May 1991. This conclusion is probative as it is based on facts presented by both the service treatment records and the assertions made by the Veteran at the time of the VA examination. There is also no competent or credible evidence or opinion that suggests that there exists a medical relationship, or nexus, between any current neck or cervical spine disability and a period of the Veteran's service. In addition, there is no evidence of degenerative arthritis in service. To determine that a chronic disease was shown in service, the disease identity must be established. 38 C.F.R. § 3.303(b); Walker, 708 F.3d at 1339. No examiner in service, or since, has established chronicity or an underlying chronic disease process in service. In sum, characteristic manifestations sufficient to identify the disease (arthritis) entity were not noted. Further, there is no demonstration of continuity of symptomatology or evidence of arthritis within one year of separation from service. Thus, service connection cannot be awarded on a presumptive basis. 38 U.S.C. § 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. § 3.303(b), 3.307, 3.309. The Veteran is competent to report his symptoms, but he is not competent to link his thoracolumbar spine disability to service or service-connected disability. The Veteran is not competent to establish that he has a low back or thoracolumbar spine disability that onset due to injury sustained during a period of service or was caused or aggravated by a service-connected disability. The Veteran is not competent to offer opinion as to etiology of any current low back or thoracolumbar spine disability. The question regarding the etiology of such disability is a complex medical issue that cannot to be addressed by a layperson. For these reasons, his allegations are non-specific and are no more than conjecture and do not rise to the type of evidence addressed by Jandreau. The claim for service connection for a low back or thoracolumbar spine disability must be denied. The preponderance of the evidence is against the claim and the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. at 53-56 (1990). 13. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) Under the applicable criteria, total disability ratings for compensation based upon individual unemployability may be assigned where the schedular rating is less than total, when it is found that the disabled person is unable to secure or follow a substantially gainful occupation as a result of a single service-connected disability ratable at 60 percent or more or, as a result of two or more disabilities, provided at least one disability is ratable at 40 percent or more and there is sufficient additional service-connected disability to bring the combined rating to 70 percent or more. See 38 C.F.R. §§ 3.340, 3.341, 4.16(a). In determining whether an individual is unemployable by reason of service-connected disabilities, consideration must be given to the type of employment for which the Veteran would be qualified. Such consideration would include education and occupational experience. Age may not be considered a factor. 38 C.F.R. § 3.341. Unemployability associated with advancing age or intercurrent disability may not be used as a basis for assignment of a total disability rating. 38 C.F.R. § 4.19. For a Veteran to prevail on a total rating claim, the record must reflect some factor which takes his or her case outside of the norm. See Van Hoose v. Brown, 4 Vet. App. 361, 363 (1996); 38 C.F.R. §§ 4.1, 4.15. The sole fact that a Veteran happens to be unemployed or has difficulty obtaining employment is not enough. A high rating is recognition that the impairment makes it difficult to obtain and keep employment. The question is whether the Veteran is capable of performing the physical and mental acts required by employment, not whether the Veteran can find employment. See Van Hoose, supra, at 363; 38 C.F.R. § 4.16 (a). The fact that a Veteran is unemployed is generally insufficient to demonstrate that he is considered "unemployable" within the meaning of pertinent VA laws and regulations. Instead, a longitudinal review of all the evidence is necessary in order to obtain a full understanding of the case. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Service-connection is currently in effect for posttraumatic stress disorder (PTSD) (50 percent disabling); seborrheic dermatitis (10 percent disabling); right knee chondromalacia (10 percent disabling); left knee Palligrini-Stieda's disease with chondromalacia (10 percent disabling); and, bilateral pes planus (10 percent disabling); the combined rating for these service-connected disabilities is 70 percent. The November 2018 VA PTSD examination report reflects that the Veteran's PTSD caused occupational and social impairment with reduced reliability and productivity. The Veteran reported that he had not been employed since he was discharged from the military. The February 2019 VA skin diseases examination reflects that the Veteran's seborrheic dermatitis had no impact on his ability to work. The February 2019 VA foot conditions examination reflects that the Veteran's bilateral pes planus had no impact on his ability to work. The February 2019 VA knee and lower leg conditions examination reflects that the Veteran's left and right knee disabilities impacted his ability to work. The examiner documented that the Veteran lost approximately a week of work in the last year. However, a February 2019 individual unemployability statement concerning the Veteran's right and left knee disabilities reflects that the Veteran was able to perform sedentary work. The Veteran's application for a TDIU received in August 2020 reflects that his shoulders, knees, back and head injuries prevents him from securing or following a substantially gainful occupation. The Veteran reported that he became too disabled to work on January 1, 1992. The Veteran reported that he had completed high school and 2 years of college and had additional training as an automotive diesel technician. In a lay statement received in March 2021, the Veteran reported that due to his shoulder disorders he could hardly lift his arms over his head and was prevented from having gainful employment. He also asserts his back, knees and other claimed disabilities prevent him from obtaining gainful employment. The Board reiterates that the shoulders, back, residuals of a TBI and "other claimed" disabilities are not service connected as adjudicated above. The preponderance of the evidence of record weighs against finding that the Veteran's service-connected right and left knee, seborrheic dermatitis, bilateral pes planus and PTSD disabilities, without consideration of non-service-connected disabilities, preclude him from obtaining or engaging in any form of substantially gainful employment. In reaching this conclusion, the Board has considered the Veteran's lay assertions. The Veteran is competent to describe the symptoms and associated limitations of his disabilities. However, as noted the February 2019 VA skin diseases and February 2019 VA foot conditions examinations reflect that the Veteran's seborrheic dermatitis and bilateral pes planus had no impact on his ability to work. Further, the February 2019 individual unemployability statement concerning the Veteran's right and left knee disabilities reflects that the Veteran was able to perform sedentary work. Similarly, though the November 2018 VA PTSD examination report reflects that the Veteran's PTSD caused occupational and social impairment with reduced reliability and productivity and that the Veteran had not been employed since he was discharged from the military, the examination does not indicate that the Veteran was incapable of performing the physical and mental acts required by employment due to his service-connected PTSD. Thus, the Board concludes that the evidence shows that the Veteran was not unemployable due solely to his service-connected disabilities. The claim is therefore denied. S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Jackson 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.