Citation Nr: 21042503 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-57 462 DATE: July 13, 2021 ORDER Entitlement to service connection for allergies, claimed as hay fever, is denied. Entitlement to service connection for a left shoulder disability is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a right ankle disability is denied. Entitlement to service connection for a left ankle disability is denied. Entitlement to service connection for a heart disability, claimed as an irregular heartbeat is denied. Entitlement to service connection for hypertension is denied REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to an increased initial evaluation in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to a service-connected disability is remanded. FINDINGS OF FACT 1. The weight of the competent and credible evidence is against finding that the Veteran's allergic rhinitis manifested in service and is against finding that the disorder was etiologically caused by an in-service injury or disease. 2. The weight of the competent and credible evidence is against finding that the Veteran's left shoulder rotator cuff tendonitis and degenerative joint disease (DJD) manifested in service or within one year of service; and is not etiologically caused by an in-service injury, event or disease. 3. The weight of the competent and credible evidence is against finding that the Veteran's right knee patellofemoral pain syndrome and degenerative arthritis manifested in service or within one year of service; and is not etiologically caused by an in-service injury, event or disease. 4. The weight of the competent and credible evidence is against finding that the Veteran's right ankle tendonitis manifested in service and is against finding that such was etiologically caused by an in-service injury or disease. 5. The weight of the competent and credible evidence is against finding that the Veteran's left ankle tendonitis and degenerative arthritis manifested in service or within one year of service; and is not etiologically caused by an in-service injury, event or disease. 6. The weight of the competent and credible evidence is against finding that the Veteran's heart disability, including palpations and a right bundle branch block manifested in service or within one year of service; and is not etiologically caused by an in-service injury, event or illness. 7. The weight of the competent and credible evidence is against finding that the Veteran's high blood pressure manifested in service or within one year of service; and is not etiologically caused by an in-service injury, event or illness. CONCLUSIONS OF LAW 1. The criteria for service connection for allergic rhinitis have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.309 (2020). 2. The criteria for service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.309 (2020). 3. The criteria for service connection for a right knee disability have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.309 (2020). 4. The criteria for service connection for a right ankle disability have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.309 (2020). 5. The criteria for service connection for a left ankle disability have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.309 (2020). 6. The criteria for service connection for a heart disability have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.309 (2020). 7. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.309 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from July 1989 to March 1995 with service in Southwest Asia from April to October 1991. These matters come before the Board of Veterans' Appeals (Board) from an October 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Previously, the Veteran's claims were before the Board in February 2019, and were remanded for additional development. There has been substantial compliance with the prior remand directives, and the matters again are before the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. §§ 1110, 1131. To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 Fed. Cir. (2004). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303 (b), 3.309. In addition, the Veteran served in the Southwest Asia theater of operations during the applicable time period. 38 C.F.R. § 3.317 (e). Under those provisions, service connection may be established for objective indications of a chronic disability resulting from an undiagnosed illness or illnesses, provided that such disability (1) became manifest in service on active duty in the Armed Forces in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021; and (2) by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. To fulfill the requirement of chronicity, the illness must have persisted for six months. 38 U.S.C. § 1117; 38 C.F.R. § 3.317. Signs or symptoms which may be manifestations of undiagnosed illness include, but are not limited to: fatigue, signs or symptoms involving skin, headache, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system (upper or lower), sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, and menstrual disorders. 38 C.F.R. § 3.317 (b). There must be objective signs that are perceptible to an examining physician and other non-medical indicators that are capable of independent verification. There must be a minimum of a six-month period of chronicity. There must be no affirmative evidence that relates the illness to a cause other than being in the Southwest Asia theater of operations during the Persian Gulf War. If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98 (Aug. 3, 1998). For purposes of this section, a qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; (B) the following medically unexplained chronic multisymptom illnesses that are defined by a cluster of signs or symptoms: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) irritable bowel syndrome; or (4) any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multisymptom illness; or (C) any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service-connection. 38 C.F.R. § 3.317(a)(2)(i). For purposes of this section, the term medically unexplained chronic multisymptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multisymptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). For purposes of this section, "objective indications of chronic disability" include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3). Compensation shall not be paid under this section, however, if there is affirmative evidence that an undiagnosed illness was not incurred during active military, naval, or air service in the Southwest Asia theater of operations during the Persian Gulf War; or if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the Veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the Veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317 (c). Service personnel records show that the Veteran served as an automated logistics specialist 1. Entitlement to service connection for allergies The Veteran contends that service connection is warranted for allergies, to include hay fever. The Veteran contends that his current allergic rhinitis is related to service. The Veteran reports that his hay fever and allergies developed while he was serving in Southwest Asia and occurred again while he was painting a military building at Fort Bliss. The Veteran reports while serving in Southwest Asia he was exposed to smoke and chemicals in the air and that these exposures lead to his current allergies. The Veteran is competent to describe his current symptoms, in-service events, and the occurrence of ongoing symptoms, and to this extent, these statements are credible. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The question for the Board is whether the Veteran has a current allergy disability that began during service or is at least as likely as not caused by an in-service injury or disease. The Veteran has a diagnosis of allergic rhinitis. The Veteran's available service treatment records (STRs) and service personnel records have been associated with the claims file. Personnel records note the Veteran served in Southwest Asia during the applicable time period from April 1991 to August 1991. STRs note in September 1993 the Veteran was seen for swelling on his face and neck. The Veteran reported that he was painting and started feeling weird, and his vision became blurry and his neck and around his mouth became swollen. Physical examination noted that the Veteran was dizzy and was given Benadryl. When the swelling continued, he was given epinephrine. An allergic reaction to paint was noted and discharge notes indicate the Veteran was to have no further paint exposure. The Veteran was prescribed 24 hours of bedrest and to return for care as needed. The Veteran was discharged the same day to his unit and prescribed Benadryl and associated medications until his symptoms resolved. Based on the Veteran's statements, testimony and treatment records the Board finds an in-service onset of some possibly related symptoms such as reports of difficulty breathing but without a clear diagnosis of allergic rhinitis. The Veteran was afforded a VA examination in May 2016. The Veteran reported seasonal hyperreaction to environmental allergens with itchy eyes and sneezing. The Veteran reported that at times he can experience itchy red eyes from walking outside. In-service the Veteran reports that he experienced facial swelling which was treated with Benadryl. The Veteran denied sinus pain, pressure or infection. The Veteran reported taking Zyrtec for allergies. The examiner noted allergic rhinitis with a greater than 50 percent obstruction of the nasal passage on both sides. A complete obstruction on the left or right side due to rhinitis was not noted. There was no evidence of nasal polyps or a granulomatous condition. The examiner noted no additional pertinent physical findings, complications, conditions or signs related to his rhinitis. Pulmonary function testing noted a forced expiratory volume after one second (FEV-1) of 71 to 80 percent predicted. The examiner noted that the Veteran's rhinitis does not impact his ability to work. The examiner noted a review of the Veteran's STRs and that he was seen in September 1993 for periorbital swelling. The STRs noted no persistent or chronic allergic reaction. The Veteran was treated for an instance of a single allergic reaction in service in September 1993. The Veteran reported that he currently experiences hay fever and seasonal allergies. The examiner noted no that a physical examination of the Veteran supports a finding of chronic allergic rhinitis. The examiner found that it is less likely than not that the Veteran's current allergic rhinitis is related to service, or was incurred in or caused by service, to include one episode of an acute reaction to an allergen in September 1993. Then, the Veteran was afforded a VA opinion in January 2020. The examiner found that it was less likely than not that the Veteran's allergic rhinitis was incurred in or caused by service, including the Veteran's service in Southwest Asia and associated exposures. The examiner noted a thorough review of the Veteran's claims file. The examiner noted that a review of the STRs noted evaluation, diagnosis and treatment for allergic rhinitis was not found during service. Further, the examiner noted a review of the medical literature including the National Academy of Sciences (NAS) publication Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War (2016). The examiner noted that a thorough review of the summary of conclusions regarding associations between deployments in the Gulf War and specific health conditions noted inadequate/insufficient evidence to determine whether an association exists regarding respiratory conditions. The examiner noted that the Veteran's physical exam and diagnostic studies do not reveal any undiagnosed illness or diagnosed medically unexplained chronic multi symptoms illness. The Veteran's allergic rhinitis is attributed to a clearly defined diagnosis that has not been shown to have sufficient evidence of an association with his Gulf War service. The examiner further noted based on a review of the medical literature there is no credible medical authority, peer reviewed study or Department of Defense (DoD)/VA directives that have established a link between Southwest Asia service and these conditions. The examiner noted that the Veteran does not report any history or symptoms consistent with any medically unexplained chronic multi symptom illnesses which have been shown to have sufficient evidence of an association to exposures in the Gulf War. As such the examiner found that the Veteran's allergic rhinitis was less likely than not incurred in or caused by service. VA and private treatment records have been associated with the claims file. October 2006 treatment records note the Veteran had allergic rhinitis with symptoms of itchy eyes, ears and nose. Private treatment records also note the Veteran regularly takes medication for his allergic rhinitis. These treatment records do not contradict the VA examinations and are absent indications between the Veteran's allergic rhinitis and an in-service disease or injury. After consideration of all evidence of record, the Board finds that the weight of the evidence is against finding that service connection for allergic rhinitis is warranted. The Board concludes that service connection for allergic rhinitis on a direct basis is not warranted as the Veteran's current allergic rhinitis was not caused by service. The Veteran's lay statements regarding his current symptoms and ongoing symptomology and in-service exposures are credible. While the Veteran's lay statements report that his current allergic rhinitis is related to service, the record does not reflect that he has the requisite training or expertise to offer a medical opinion linking a current disability to service and as such the Veteran is not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board finds that the medical evidence is more probative and credible than the lay opinions of record. The competent medical evidence including the May 2016 and January 2020 VA examination and opinion taken in consideration together are entitled to significant probative weight. The May 2016 VA examiner found that it is less likely than not that the Veteran's current allergic rhinitis is related to service, or was incurred in or caused by service, to include one episode of an acute reaction to an allergen in September 1993. The examiner noted a review of the Veteran's STRs and that he was seen in September 1993 for periorbital swelling. The STRs noted no persistent or chronic allergic reaction. The Veteran was treated for an instance of an allergic reaction in service in September 1993. The examiner noted consideration of the Veteran's reports that he currently experiences hay fever and seasonal allergies. In addition, the VA opinion in January 2020 found that that it was less likely than not that the Veteran's allergic rhinitis was incurred in or caused by service, including the Veteran's service in Southwest Asia. The examiner noted a thorough review of the Veteran's claims folder, his contentions and service in Southwest Asia. The examiner noted a review of the medical literature including the NAS publication Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War (2016). The examiner noted that a review of the summary of conclusions regarding associations between deployment to the Gulf War and specific health conditions which noted inadequate/insufficient evidence to determine whether an association exists regarding respiratory conditions. The examiner noted that the Veteran's physical exam and diagnostic studies do not reveal any undiagnosed illness or diagnosed medically unexplained chronic multi symptoms illness. The Veteran's allergic rhinitis is attributed to a clearly defined diagnosis that has not been shown to have sufficient evidence of an association with Gulf War service. The examiner further noted based on a review of the medical literature there is no credible medical authority, peer reviewed study or Department of Defense/VA directives that have established a link between Southwest Asia service and allergic rhinitis. The examiner noted that the Veteran does not report any history or symptoms consistent with any medically unexplained chronic multi symptom illnesses which have been shown to have a sufficient evidence of an association to exposures in the Gulf War. The Board finds that direct service connection is not warranted as the Veteran's allergic rhinitis was not onset in or caused by service. The Board notes that STRs note in September 1993 the Veteran was seen for an allergic reaction to paint and was prescribed care and medication for an acute allergic reaction which included swelling of his face and neck. The Board has considered the Veteran's lay statements however, the Board gives more probative weight to the competent medical evidence especially the May 2016 and January 2020 VA examination and opinion. As such the Board finds the Veteran's current allergic rhinitis is less likely than not related to active service. In addition, although the Veteran served in Southwest Asia during the applicable time period, he cannot establish service connection for an undiagnosed illness under 38 C.F.R. § 3.317, because while there is an indication of allergic rhinitis, and as noted above the claimed condition has not been shown to be undiagnosed or part of a medically unexplained chronic multi symptom illness. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for allergic rhinitis. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 5557 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. 2. Entitlement to service connection for a left shoulder disability The Veteran contends that service connection is warranted for a left shoulder disability. The Veteran reports that his left shoulder disability developed from in-service training including carting a heavy pack on road marches and completing combat readiness training and required physical training (PT) exercises. Additionally, the Veteran reports that he injured his left shoulder in Southwest Asia. The Veteran contends that his current left shoulder disability is related to an in-service injury. The Veteran reported left shoulder symptoms since service which have worsened over time. The Veteran is competent to describe his current symptoms, in-service events, and the occurrence of ongoing symptoms. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The question for the Board is whether the Veteran has a left shoulder disability that began during service, manifested during the applicable presumptive period, or is at least as likely as not caused by an in-service injury or disease. The Veteran has a diagnosis of left shoulder rotator cuff tendonitis and degenerative joint disease (DJD). The Veteran's STRs have been associated with the claims file. An April 1991 STR noted that the Veteran reported injuring his left shoulder while playing volleyball. November 1991 STRs note the Veteran was seen for ongoing pain in his left shoulder for 3 months. X-rays were recommended. A radiologic consultation request noted that the Veteran injured his left shoulder while playing volleyball. X-ray imaging noted a left shoulder with a prior dislocation. Following the initial treatment, there was no follow up, restricted duty, or additional encounters for continued pain or dysfunction. Based on the Veteran's statements and treatment records the Board finds an in-service onset of some possibly related symptoms such as reports of shoulder pain but without a clear diagnosis of left shoulder rotator cuff tendonitis and/or DJD. The Veteran was afforded a VA examination in May 2016. The Veteran reported that he has had chronic problems with his shoulder since service with pain, stiffness and weakness. The Veteran reports popping and grinding with movement. The examiner noted left rotator cuff tendonitis. The Veteran is left hand dominant. The Veteran reports flare ups with increased pain, stiffness and weakness. Functional loss was noted with stiffness and weakness. Left shoulder range of motion testing noted flexion to 70 degrees, abduction to 70 degrees, and external and internal rotation to 40 degrees. Range of motion contributes to functional loss with decreased flexibility and pain was noted on exam which causes functional loss. Repetitive use testing did not result in any additional functional loss or range of motion. Muscle strength testing of the left shoulder was 3/5, and the reduction in muscle strength is due to the claimed condition. No muscle atrophy was noted. No left sided ankylosis was noted. A rotator cuff condition of the left shoulder was noted with positive Hawkins' Impingement Test, positive empty-can test. Shoulder instability was noted with a positive crank apprehension and relocation test. Imaging noted left shoulder arthritis. X-ray imaging noted mild to moderate left degenerative changes involving the AC joints. The examiner noted that the Veteran's left shoulder condition impacts his ability to perform occupational tasks in that the Veteran's shoulder condition would limit his ability to perform repetitive heavy lifting, pushing or pulling, as well as any overhead work at all. The examiner found that it is less likely than not that the Veteran's left shoulder disability was proximately due to or caused by his military service. The examiner noted a review of the Veteran's claims file including his STRs and a left shoulder injury in late 1991, along with a brief period of treatment that was documented. However, there was no further documentation of shoulder problems until 2012. Thus, the examiner found that there was no evidence of chronicity of left shoulder problems. Currently X-ray imaging noted bilateral AC joint DJD. The examiner found that it is less likely than not that the Veteran's current left shoulder disability is related to service. VA and private treatment records have been associated with the claims file. May 2012 private treatment records note an onset of left shoulder pain several months prior. VA treatment records in August 2013 note left shoulder DJD. In October 2013, the Veteran reported to a clinician that he had trouble sleeping after exercising vigorously. These treatment records do not contradict the VA examination and are absent indications between the Veteran's current left shoulder disability and an in-service disease or injury. The Veteran's contention of a continuity of pain since service is not supported by these records as he did not mention injuries in service or continued pain for decades as would have been appropriate to assist the providers with diagnosis and treatment. Therefore, the report of continuity since service warrants low probative weight. After consideration of all the evidence of record the Board finds that the weight of the evidence is against finding that service connection for a left shoulder disability is warranted. The Board concludes that service connection for a left shoulder disability is not warranted on a direct basis as the Veteran's current left shoulder disability was not caused by service. The Veteran's lay statements regarding his current symptoms and ongoing symptomology and in-service exposures are credible. While the Veteran's lay statements report that his current left shoulder rotator cuff tendonitis and DJD are related to service, the record does not reflect that he has the requisite training or expertise to offer a medical opinion linking a current disability to service and as such the Veteran is not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board finds that the medical evidence is more probative and credible than the lay opinions of record. The competent medical evidence including the May 2016 VA examination is entitled to significant probative weight. The May 2016 VA examiner found that it is less likely than not that the Veteran's left shoulder disability was proximately due to or caused by his military service. The examiner noted a review of the Veteran's STRs and a left shoulder injury in late 1991, along with a brief period of treatment that was documented. The examiner noted a thorough review of the Veteran's claims file and consideration of his statements but noted no further shoulder problems until 2012. The examiner noted no evidence of chronicity of left shoulder problems. The examiner found that it is less likely than not that the Veteran's current left shoulder disability is related to service. The Board finds that direct service connection is not warranted as the Veteran's current left shoulder rotator cuff tendonitis and DJD was not onset in or caused by service. The Board notes the Veteran was seen in-service on several occasions in 1991, after a volleyball injury and ongoing left shoulder pain. STRs noted evidence of a prior shoulder dislocation. The Board has considered the Veteran's lay statements however, the Board gives more probative weigh to the competent medical evidence especially the May 2016 VA examination. As such the Board finds the Veteran's current left shoulder rotator cuff tendonitis and DJD is less likely than not related to active service As to presumptive service connection, the Veteran's degenerative arthritis of the left shoulder did not manifest until many years post-service. The Board concludes that while the Veteran has arthritis, which falls within a chronic disease under 38 U.S.C. § 1101 (3)/38 C.F.R. § 3.309(a), however such was not chronic in service nor did this manifest to a compensable degree in service or within the presumptive period, and continuity of symptomatology is not established. The Veteran's arthritis was not noted during service or within one year of separation. See Walker, 708 F.3d 1331. Service records do not support an onset of the Veteran's arthritis in active service. The first indication of arthritis of the left shoulder was in 2013, over 15 years after the Veteran's separation from service. Based on the probative evidence of record the Board finds that the Veteran's arthritis did not manifest within the one-year period after service and service connection is not warranted on a presumptive basis. In addition, in weighing the evidence of record the Board finds the competent and credible evidence of record is against finding continuity of symptomatology. As a result, service connection based on continuity of symptomology is not warranted. In addition, although the Veteran served in Southwest Asia during the applicable time period, he cannot establish service connection for an undiagnosed illness under 38 C.F.R. § 3.317, because while there is an indication of left shoulder rotator cuff tendonitis and DJD, as noted above the claimed condition has not been shown to be undiagnosed or part of a medically unexplained chronic multi symptom illness. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a left shoulder disability. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 5557 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. 3. Entitlement to service connection for a right knee disability The Veteran contends that service connection is warranted for a right knee disability. The Veteran reports that his right knee disability is related to service. The Veteran contends that his right knee disability developed during PT and combat readiness training and in-service road marches. Further, the Veteran attributes his current right knee disability is due to excessive running and jumping while serving on active duty. The Veteran reports chronic knee pain since service, and currently has discomfort and difficulty bending his knee at times. The Veteran is competent to describe his current symptoms, in-service events, and the occurrence of ongoing symptoms. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The question for the Board is whether the Veteran has a right knee disability that began during service, manifested during the applicable presumptive period, or is at least as likely as not caused by an in-service injury or disease. The Veteran has a diagnosis of right knee patellofemoral pain syndrome and degenerative arthritis. The Veteran's STRs have been associated with the claims file. STRs note that the Veteran was seen in November 1992 for left knee pain for 5 days after playing basketball. The Veteran was not seen for or treated for any right knee symptomology. Based on the Veteran's statements the Board finds an in-service onset of some possibly related symptoms of right knee pain but without a clear diagnosis of a right knee disability. The Veteran was afforded a VA examination in May 2016. The Veteran reported chronic bilateral knee pain since service. Currently the Veteran reports daily discomfort and difficulty occasionally bending his knee. The examiner noted right knee patellofemoral pain syndrome and degenerative arthritis. The examiner noted a thorough review of the Veteran's claims file. The examiner noted STRs noted a left knee sprain with several months of discomfort. Post-service X-rays noted joint effusion and chondromalacia patella of the left knee only in 2007. Treatment in October 2013 noted mild DJD of the right knee. The Veteran reported flare ups with increased pain and stiffness. Functional loss was noted with stiffness bilaterally. Right knee range of motion testing noted flexion from 0 to 130 degrees and extension from 130 to 0 degrees. Infrapatellar and medial joint line tenderness was noted. Repetitive use testing did not result in additional loss of range of motion. Right knee strength testing was 5/5, with no muscle atrophy. No right knee ankylosis was noted. Joint stability testing was normal. X-ray imaging noted degenerative arthritis. The examiner noted that the Veteran's right knee disability impacts his ability to perform occupational tasks in that it limits his ability to perform repetitive climbing or squatting. The examiner found that it is less likely than not that the Veteran's current right knee patellofemoral pain syndrome and degenerative joint disease is proximately due to or caused by military service. The examiner noted a thorough review of the Veteran's claims file. STRs documented chronic left knee discomfort in 1992 and 1993, however there was no documentation of right knee problems. Imaging in 2007, only noted recurrent left knee pain and chondromalacia patella. Current clinical examination revealed bilateral knee tenderness and stiffness. Current imaging noted bilateral moderate DJD. As such based on a review of the claims file and the evidence of record the examiner found that it is less likely than not that the Veteran's current right knee disability is related to service. VA and private treatment records have been associated with the claims file. Private treatment records in February 2007 noted a left knee suprapatellar joint effusion and chondromalacia of the patella. December 2011 private treatment records noted bilateral knee pain. In October 2013, the Veteran reported to a clinician that he had trouble sleeping after exercising vigorously. These treatment records do not contradict the VA examination and are absent indications between the Veteran's current left shoulder disability and an in-service disease or injury. The Veteran's contention of a continuity of pain since service is not supported by these records as he did not mention injuries in service or continued pain for decades as would have been appropriate to assist the providers with diagnosis and treatment. Therefore, the report of continuity since service warrants low probative weight. After consideration of all the evidence of record the Board finds that the weight of the evidence is against finding that service connection for a right knee disability is warranted. The Board concludes that service connection for right knee patellofemoral pain syndrome and degenerative arthritis is not warranted. The Board concludes that service connection for a right knee disability on a direct basis is not warranted as the Veteran's current right knee disability was not caused by service. The Veteran's lay statements regarding his current symptoms and ongoing symptomology and in-service exposures are credible. While the Veteran's lay statements report that his current right knee disability is related to service, the record does not reflect that he has the requisite training or expertise to offer a medical opinion linking a current disability to service and as such the Veteran is not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board finds that the medical evidence is more probative and credible than the lay opinions of record. The competent medical evidence including the May 2016 VA examination is entitled to significant probative weight. The May 2016 VA examiner found that it is less likely than not that the Veteran's current right knee patellofemoral pain syndrome and degenerative joint disease is proximately due to or caused by military service. The examiner noted a thorough review of the Veteran's claims file. STRs documented chronic left knee discomfort in 1992 and 1993, however there was no documentation of right knee problems. Imaging in 2007, only noted recurrent left knee pain and chondromalacia patella. Current clinical examination revealed bilateral knee tenderness and stiffness. Current imaging notes bilateral moderate DJD. As such based on a review of the claims file and the evidence of record the examiner found that it is less likely than not that the Veteran's current right knee disability is related to service. The Board finds that direct service connection is not warranted as the Veteran's current right knee disability was not onset in or caused by service. The Board notes that STRs note in November 1992 the Veteran was seen for a left knee injury while playing basketball, and ongoing pain and follow-up associated with such. The Board has considered the Veteran's lay statements however the Board gives more probative weight to the competent medical evidence especially the May 2016 VA examination. As such the Board finds that the Veteran's current right knee disability is less likely than not related to active service. As to presumptive service connection, the Veteran's degenerative arthritis of the right knee did not manifest until many years post-service. The Board concludes that while the Veteran has arthritis, which falls within a chronic disease under 38 U.S.C. § 1101 (3)/38 C.F.R. § 3.309(a), however such was not chronic in service nor did these manifest to a compensable degree in service or within the presumptive period, and continuity of symptomatology is not established. The Veteran's arthritis was not noted during service or within one year of separation. See Walker, 708 F.3d 1331. Service records do not support an onset of the Veteran's arthritis in active service. Based on the probative evidence of record the Board finds that the Veteran's arthritis did not manifest within the one-year period after service and service connection is not warranted on a presumptive basis. In addition, in weighing the evidence of record the Board finds the competent and credible evidence of record is against finding continuity of symptomatology. As a result, service connection based on continuity of symptomology is not warranted. In addition, although the Veteran served in Southwest Asia during the applicable time period, he cannot establish service connection for an undiagnosed illness under 38 C.F.R. § 3.317, because while there is an indication of right knee patellofemoral pain syndrome and degenerative arthritis, as noted above the claimed condition has not been shown to be undiagnosed or part of a medically unexplained chronic multi symptom illness. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a right knee disability. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 5557 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. 4. Entitlement to service connection for a right ankle disability 5. Entitlement to service connection for a left ankle disability The Veteran contends that service connection is warranted for a right ankle disability. In addition, the Veteran contends that service connection is warranted for a left ankle disability. For the sake of brevity, the Board will discuss the Veteran's claims for a right and left ankle disability together. The Veteran reports that his current right and left ankle disabilities are related to service. The Veteran reported that his right and left ankle disabilities are due to in-service PT and combat readiness training as well as wear and tear from road marches. Further, the Veteran reports that his current left ankle disability is related to his in-service injury. The Veteran is competent to describe his current symptoms, in-service events, and the occurrence of ongoing symptoms. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The question for the Board is whether the Veteran has a right and left ankle disability that began during service, manifested during the applicable presumptive period, or is at least as likely as not caused by an in-service injury or disease. The Veteran has a diagnosis of right ankle tendonitis and left ankle tendonitis and degenerative arthritis. The Veteran's STRs have been associated with the claims file. STRs note the Veteran was seen for a left lateral ankle sprain in April 1991. The Veteran reported a left ankle sprain while playing basketball when he landed on another player's foot. STRs noted a left lateral ankle sprain. The Veteran reported that he inverted his ankle when coming down. Ice, ace wrap, medication and rest was recommended. Active range of motion testing noted range of motion was reduced by approximately 10 percent. The Veteran was seen in the physical therapy clinic on several occasions and reported tenderness along the joint pain line and increased pain in the morning as to his left ankle. April 1991 STRs note the Veteran was seen for follow up in the physical therapy clinic for his left ankle. He reported that his ankle is stiff in the morning and continues to use one crutch. It was recommended that the Veteran discontinue the use of crutches and continue on a profile for one week with no running or jumping. The Board notes that the Veteran initially presented to the emergency room on April 10, 1991, there was one occasion of a notion of a right ankle injury, however such appears to be an error and rather was referencing the April 1991 left ankle sprain, due to a basketball injury. Based on the Veteran's statements and treatment records the Board finds an in-service onset of some possibly related symptoms such as reports of left ankle pain and an April 1991 basketball injury, but without a clear diagnosis of right and left ankle tendonitis or left ankle arthritis. The Veteran was afforded a VA examination in May 2016. The Veteran reported that during service he sustained recurrent bilateral ankle sprains, and that since service he has continued to have ongoing bilateral ankle discomfort. The Veteran reports that his left ankle has increased symptomology and remains weak and stiff. The examiner noted an extensive review of the Veteran's claims file. The examiner noted right ankle tendonitis and left ankle tendonitis and degenerative arthritis. The examiner noted that the Veteran reported a history of lateral collateral ligament sprains in the 1990s. The examiner noted that X-ray imaging done in October 2013 revealed mild narrowing of the left anterior tibiotalar joint and that the right ankle was normal. The examiner noted that STRs documented an acute left ankle sprain in 1991, with normal X-ray imaging. The Veteran reported flare ups of his ankles with increased pain and stiffness. Functional loss was noted with stiffness on his left ankle. Range of motion testing of the right ankle noted normal range of motion with no evidence of pain or localized tenderness. Left ankle range of motion testing noted dorsiflexion from 0 to 15 degrees and plantar flexion from 0 to 35 degrees with pain. Localized tenderness was noted with pain on local lateral malleolar tenderness. Repetitive use testing did not result in any additional loss of range of motion bilaterally. Muscle strength testing noted right ankle strength of 5/5. Left ankle muscle strength was 3/5 on plantar flexion and 4/5 on dorsiflexion. No muscle atrophy was noted. Joint stability testing was normal. X-ray imaging noted left ankle degenerative arthritis. The examiner noted that the Veteran's current left ankle condition impacts his ability to perform occupational tasks in that it limits his ability to perform repetitive climbing or squatting. The VA examiner found that it is less likely than not that the Veteran's current right and left ankle disability is proximately due to or the result of service. The examiner noted a thorough review of the Veteran's claims file. Further, the examiner noted that the Veteran was seen in-service in April 1991 for an acute left ankle sprain, with negative X-rays and a brief period of follow-up. Post-service treatment records documented left ankle pain in 2012 which is over 20 years after the acute episode in-service, and with no clinical documentation of ongoing symptoms between these episodes. The examiner noted no documentation of any right ankle problems in-service. The examiner noted that the Veteran currently experiences mild bilateral ankle tendonitis and some stiffness/weakness on his left ankle. As such the examiner found that it is less likely than not that the Veteran's current right and left ankle disability is related to service. Then the Veteran was afforded a VA opinion in October 2019. The VA examiner noted that the Veteran's right ankle disability was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that the Veteran's STRs are silent for a right ankle condition. The examiner noted that STRs noted a diagnosis of a right ankle sprain however, further evaluation and examination noted a left ankle injury. Further imaging noted X-rays were done to rule out a left ankle fracture and were normal. This error initially noted in the emergency room, of a right ankle injury, was corrected to a left ankle sprain at subsequent follow ups and then again physical therapy and follow ups noted ongoing monitoring and follow up for the Veteran's left ankle sprain. The examiner noted that the notation of a right ankle sprain was in error on April 6, 1991. The earliest documentation of a right ankle disability was in August 2013. The Veteran's reported history of degenerative joint disease of the ankles bilaterally is not supported by the objective medical evidence. Further, while the May 2016 examiner noted a lateral collateral ligament sprain which was diagnosed in the 1990s. The examiner was not noting a current diagnosis of a lateral collateral ligament sprain rather relaying that the Veteran reported this by history from the 1990s. The VA examination in May 2016 indicated that the examination was consistent with mild right ankle tendinitis and a normal X-ray. The examiner noted that there is no nexus between the Veteran's current right ankle tendonitis and his service. VA and private treatment records have been associated with the claims file. A review of these records shows that the earliest self-reports of ankle symptoms began in 2012 when the Veteran reported bilateral ankle pain. In October 2013, the Veteran reported to a clinician that he had trouble sleeping after exercising vigorously. These treatment records do not contradict the VA examination and are absent indications between the Veteran's current left shoulder disability and an in-service disease or injury. The Veteran's contention of a continuity of pain since service is not supported by these records as he did not mention injuries in service or continued pain for decades as would have been appropriate to assist the providers with diagnosis and treatment. Therefore, the report of continuity since service warrants low probative weight. After consideration of all the evidence of record the Board finds that the weight of the evidence is against finding that service connection for a right and left ankle disability is warranted. The Board concludes that service connection for a right ankle disability and service connection for a left ankle disability on a direct basis is not warranted as the Veteran's current right and left ankle disabilities were not caused by service. The Veteran's lay statements regarding his current symptoms, in-service events and ongoing symptomology warrant low probative weight. While the Veteran reports that his current right and left ankle disabilities are generally related to service and an in-service injury the record does not reflect that he has the requisite training or expertise to offer a medical opinion linking a current disability to service and as such the Veteran is not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board finds that the medical evidence is more probative and credible than the lay opinions of record. The competent medical evidence including specifically the VA examination in May 2016 and October 2019 VA opinion taken in consideration together are entitled to significant probative weight. The VA examiner in May 2016 noted right ankle tendonitis and left ankle tendonitis and degenerative arthritis. The examiner noted that the Veteran reported a history of lateral collateral ligament sprains in the 1990s. The examiner noted that X-ray imaging done in October 2013 revealed mild narrowing of the left anterior tibiotalar joint and that the right ankle was normal. The examiner noted that STRs documented an acute left ankle sprain in 1991, with normal X-ray imaging. The VA examiner found that it is less likely than not that the Veteran's current right and left ankle disability is proximately due to or the result of service. The examiner noted a thorough review of the Veteran's claims file. Further, the examiner noted that the Veteran was seen in-service in April 1991 for an acute left ankle sprain, with negative X-rays and a brief period of follow-up. Post-service treatment records documented left ankle pain in 2012 which is over 20 years after the acute episode in-service, and with no clinical documentation of ongoing symptoms between these episodes. The examiner noted no documentation of any right ankle problems in-service. The examiner noted that the Veteran currently experiences mild bilateral ankle tendonitis and some stiffness/weakness on his left ankle. As such the examiner found that it is less likely than not that the Veteran's current right and left ankle disability is related to service. The VA opinion in October 2019 noted that the Veteran's right ankle disability was less likely than not incurred in or caused by the claimed in-service injury, event or illness. The examiner noted that the Veteran's STRs are silent for a right ankle condition. The examiner noted that STRs noted a diagnosis of a right ankle sprain however, further evaluation and examination noted a left ankle injury. Further imaging noted X-rays were done to rule out a left ankle fracture and were normal. This error initially noted in the emergency room, of a right ankle injury, was corrected to a left ankle sprain at subsequent follow ups and then again physical therapy and follow ups noted ongoing monitoring and follow up for the Veteran's left ankle sprain. The examiner noted that the notation of a right ankle sprain was in error on April 6, 1991. The earliest documentation of a right ankle disability was in August 2013. The Veteran's reported history of degenerative joint disease of the ankles bilaterally is not supported by the objective medical evidence. Further, while the May 2016 examiner noted a lateral collateral ligament sprain which was diagnosed in the 1990s. The examiner was not noting a current diagnosis of a lateral collateral ligament sprain rather relaying that the Veteran reported this by history from the 1990s. The VA examination in May 2016 indicated that the examination was consistent with mild right ankle tendinitis and a normal X-ray. The examiner noted that there is no nexus between the Veteran's current right ankle tendonitis and his service. As such the Board finds the Veteran's current right and left ankle disabilities are less likely than not caused by active service. As to presumptive service connection, the Veteran's degenerative arthritis of the left ankle did not manifest until many years post-service. The Board concludes that while the Veteran has left ankle arthritis, which falls within a chronic disease under 38 U.S.C. § 1101 (3)/38 C.F.R. § 3.309(a), however such was not chronic in service nor did these manifest to a compensable degree in service or within the presumptive period, and continuity of symptomatology is not established. The Veteran's left ankle arthritis was not noted during service or within one year of separation. See Walker, 708 F.3d 1331. Service records do not support an onset of the Veteran's arthritis in active service. Based on the probative evidence of record the Board finds that the Veteran's arthritis did not manifest within the one-year period after service and service connection is not warranted on a presumptive basis. In addition, in weighing the evidence of record the Board finds the competent and credible evidence of record is against finding continuity of symptomatology. As a result, service connection based on continuity of symptomology is not warranted. In addition, although the Veteran served in Southwest Asia during the applicable time period, he cannot establish service connection for an undiagnosed illness under 38 C.F.R. § 3.317, because while there is an indication of right ankle tendinitis, left ankle tendinitis and arthritis, as noted above the claimed condition has not been shown to be undiagnosed or part of a medically unexplained chronic multi symptom illness. In conclusion, the Board finds that the weight of competent and credible evidence is against the Veteran's claim for service connection for a right ankle disability and service connection for a left ankle disability. The benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 5557 (1990); 38 C.F.R. § 3.102. For these reasons, the claims are denied. 6. Entitlement to service connection for a heart disability The Veteran contends that service connection is warranted for a heart disability, to include an irregular heartbeat. The Veteran contends that that he developed an irregular heartbeat from stress and stressors of being deployed in Southwest Asia. Further, the Veteran contends that his irregular heartbeat is due to his service in Southwest Asia and exposure to dangerous gases. The Veteran is competent to describe his current symptoms, in-service events, and the occurrence of ongoing symptoms. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The question for the Board is whether the Veteran has a heart disability that began during service, manifested during the applicable presumptive period, or is at least as likely as not caused by an in-service injury or disease. The Veteran has a diagnosis of palpitations and a right bundle branch block. The Veteran's STRs have been associated with the claims file. As noted above the Veteran served in Southwest Asia during the applicable time period. The Board finds an in-service event in that the Veteran had service in Southwest Asia during the applicable timer period. However, there was no indication of ongoing symptomology, a heart disability or any associated symptomology. The Veteran was afforded a VA examination in May 2016. The examiner noted that the Veteran does not have a current or has not been diagnosed with a current heart condition. The examiner noted that the Veteran has a history of hypertension and reported abnormal ECG findings. A review of the Veteran's medical records shows that a persistent right bundle branch block with a normal stress echocardiogram was noted in 2008. The examiner noted that the Veteran does not have a heart condition which qualifies under the accepted medical definition of ischemic heart disease. The Veteran does not require continuous medication for control of a heart condition. He has not had a myocardial infarction or congestive heart failure. No heart valve condition, infectious heart condition or pericardial adhesions. Physical examination noted a heart rate of 57 with regular heart rhythm. Heart sounds were normal, with no jugular venous distension, clear auscultation of the lungs and normal peripheral pulses. Trace peripheral edema of the bilateral lower extremities was noted. Blood pressure was 132/91. There was no evidence of cardiac hypertrophy or cardiac dilation. A May 2016 EKG noted a right bundle branch block (RBBB). A chest X-ray was normal. A stress echocardiogram noted no ischemia and ECG portion with RBBB with normal ejection fraction. The examiner noted that the Veteran's heart condition does not impact his ability to work. Then the Veteran was afforded a VA opinion in January 2020. The examiner noted that a review of the evidence of records are silent for evaluations, diagnosis and/or treatments for any type of heart condition in-service. The examiner found that the Veteran's current heart condition is less likely than not incurred in or caused by his service. The examiner noted a review of the medical literature including NAS publication Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf Way (2016). The NAS summary of conclusion regarding deployment to the Gulf War and specific health conditions noted that there is inadequate/insufficient evidence to determine whether an association exists relating to cardiovascular conditions. The examiner further noted a review of the Veteran's treatment records and physical exam and diagnostic studies does not reveal any undiagnosed illness or a diagnosed medically unexplained chronic multi symptom illness. Rather the Veteran's claimed heart condition is attributable to a known clearly defined diagnosis, palpations and a RBBB, and such has not been shown to have sufficient evidence of an association with Gulf War service. The examiner noted no evidence of a credible medical authority, peer reviewed study, or DoD/VA directive that has established a link between Southwest Asia service and the Veteran's heart disability. Further, the Veteran does not report any history of symptoms that are consistent with any medically unexplained chronic multi-symptom illnesses which have been shown to have sufficient evidence of an association with Gulf War service. The examiner noted that he Veteran's heart disability is attributable to a clearly known and manifested disability and such did not arise in or is otherwise etiologically related to service. VA and private treatment records have been associated with the claims file. A review of these records shows the earliest self-reports of concerns was in 2008. Private treatment records note palpitations and an abnormal EKG with RBBB. A March 2017 Holter monitor report noted a right bundle branch block and a rare sinus arrythmia. These treatment records do not contradict the examinations and are absent indications between the Veteran's current heart disability and an in-service disease or injury. After consideration of all the evidence of record the Board finds that the evidence is against finding that service connection for a heart disability is warranted. The Board concludes that service connection for a heart disability on a direct basis is not warranted as the Veteran's current heart disability was not caused by service. The Veteran's lay statements regarding his current symptoms, in-service events and ongoing symptomology are warranted low probative weight. While the Veteran reports that his current heart disability is related to service and an in-service injury the record does not reflect that he has the requisite training or expertise to offer a medical opinion linking a current disability to service and as such the Veteran is not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board finds that the medical evidence is more probative and credible then the lay opinions of record. The competent medical evidence including the VA examination in May 2016 and January 2020 VA opinion, taken in consideration together are entitled to significant probative weight. The VA examiner in May 2016 found that a review of the Veteran's medical records shows that a persistent right bundle branch block with a normal stress echocardiogram was noted in 2008. The examiner noted that the Veteran does not have a heart condition which qualifies under the accepted medical definition of ischemic heart disease. The VA examiner in January 2020 noted that a review of the evidence of records are silent for evaluations, diagnosis and/or treatments for any type of heart condition in-service. The examiner found that the Veteran's current heart condition is less likely than not incurred in or caused by his service. The examiner noted a review of the medical literature including NAS publication Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf Way (2016). The NAS summary of conclusion regarding deployment to the Gulf War and specific health conditions noted that there is inadequate/insufficient evidence to determine whether an association exists relating to cardiovascular conditions. The examiner further noted a review of the Veteran's treatment records and physical exam and diagnostic studies does not reveal any undiagnosed illness or a diagnosed medically unexplained chronic multi symptom illness. Rather the Veteran's claimed heart condition is attributable to a known clearly defined diagnosis, palpations and a RBBB, and such has not been shown to have sufficient evidence of an association with Gulf War service. The examiner noted no evidence of a credible medical authority, peer reviewed study, or DoD/VA directive that has established a link between Southwest Asia service and the Veteran's heart disability. Further, the Veteran does not report any history of symptoms that are consistent with any medically unexplained chronic multi-symptom illnesses which have been shown to have sufficient evidence of an association with Gulf War service. The examiner noted that he Veteran's heart disability is attributable to a clearly known and manifested disability and such did not arise in or is otherwise etiologically related to service. As such the Board finds that the Veteran's current heart disability is less likely than not caused by active service. As to presumptive service connection, the Veteran's heart disability did not manifest until many years post-service. The Board concludes that while the Veteran has palpations and RBBB, which falls within a, cardiovascular-renal disease, a chronic disease under 38 U.S.C. § 1101 (3)/38 C.F.R. § 3.309(a), however such was not chronic in service nor did these manifest to a compensable degree in service or within the presumptive period, and continuity of symptomatology is not established. The Veteran's heart disability was not noted during service or within one year of separation. See Walker, 708 F.3d 1331. Service records do not support an onset of the Veteran's heart disability in active service. Based on the probative evidence of record the Board finds that the Veteran's heart disability did not manifest within the one-year period after service and service connection is not warranted on a presumptive basis. In addition, in weighing the evidence of record the Board finds the competent and credible evidence of record is against finding continuity of symptomatology. As a result, service connection based on continuity of symptomology is not warranted. In addition, although the Veteran served in Southwest Asia during the applicable time period, he cannot establish service connection for an undiagnosed illness under 38 C.F.R. § 3.317, because while there is an indication of heart disability, as noted above the claimed condition has not been shown to be undiagnosed or part of a medically unexplained chronic multi symptom illness. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a heart disability. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 5557 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. 7. Entitlement to service connection for hypertension The Veteran contends that service connection is warranted for hypertension. The Veteran contends that his high blood pressure was present throughout his military service. Further, the Veteran contends that his high blood pressure is due to stress while serving in Southwest Asia and his exposure to dangerous gases. The Veteran is competent to describe his current symptoms, in-service events, and the occurrence of ongoing symptoms. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The question for the Board is whether has a hypertension disability that began during service, manifested during the applicable presumptive period, or is at least as likely as not caused by an in-service injury or disease. The Veteran has a diagnosis of hypertension. Blood pressure measurements are expressed as diastolic divided by systolic pressure in mmHg. For VA compensation purposes, the term hypertension means that the diastolic blood pressure is predominantly 90 or greater; and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 or greater with diastolic blood pressure less than 90. 38 C.F.R. § 4.104, Diagnostic Code 7101. The Veteran's available STRs have been associated with the claims file. STRs noted blood pressure (BP) readings in March 1990 of 128/90 and the Veteran was seen for a left-hand injury and swollen left hand after playing basketball. The Veteran was prescribed medication, ice and rest. A follow-up evaluation noted a BP reading of 110/76. November 1991 STRs note a BP reading of 123/74. March 1993 STRs note bp of 120/82. September 1993 STRs noted a BP reading of 146/88. The Board finds an in-service event in that the Veteran had an instance of high blood pressure in-service in March 1990. However, there was no indication of ongoing symptomology, as evidenced by treatment records noting blood pressure within normal limits during service there was no indication of high blood pressure or associated symptomology or a diagnosis of hypertension or associated ongoing symptomology. The Veteran was afforded a VA examination in May 2016. The VA examiner noted a diagnosis of hypertension. The examiner noted that the Veteran reports that around 2003 to 2004. The Veteran currently takes continuous medication for hypertension or isolated systolic hypertension. The examiner noted that the Veteran has a history of a diastolic blood pressure elevation to predominantly 100 or more with a blood pressure reading of 158/104 in August 2013. Blood pressure readings in May 2016 of 132/91, 136/99 and 158/104 in August 2013. The average blood pressure reading was 142/98. The examiner noted that the Veteran's hypertension or isolated systolic hypertension impact his ability to work. The examiner noted that the Veteran's STRs does not support a diagnosis of hypertension in-service. Then the Veteran was afforded a VA examination in January 2020. The examiner noted that it is less likely than not that the current Veteran's hypertension was incurred in or caused by an instance of high blood pressure during service. The examiner noted a review of the Veteran's treatment records, and such are silent for evaluations, diagnoses and/or treatment for hypertension. The examiner found that it is less likely than not that the Veteran's current hypertension arose during service in March 1990. The examiner noted that the Veteran's elevated blood pressure, during that time was due to the symptoms of illness he was diagnosed with, and after treatment with medications and bedrest, the Veteran's blood pressure returned to normal. The VA examiner noted that the Veteran's physical exam and diagnostic studies do not reveal any undiagnosed illnesses or diagnosed medically unexplained chronic multi symptoms illness. The examiner noted that the Veteran's claimed conditions are attributable to a known clearly defined diagnosis that has not been shown to have sufficient evidence of an associated with Gulf War service as shown above. The examiner noted that the Veteran's claimed conditions are attributable to a known clearly defined diagnosis that has not been shown to have sufficient evidence of an association with Gulf War service as shown above. The examiner noted that there is no credible medical authority, peer reviewed study, or DoD/VA directive that has established a link between Southwest Asia service and these conditions. The Veteran does not report any history or symptoms consistent with any medically unexplained chronic multi symptom illness which have been shown to have sufficient evidence of an association as described above. As such the examiner found that it is less likely than not that the Veteran's hypertension was incurred in or caused by service. VA and private treatment records have been associated with the claims file. A review of these records shows that the Veteran's earliest self-report of symptomology related to high blood pressure began in October 2005. Medical records reflect hypertension as an active issue from this point forward. Treatment records are absent indications between the Veteran's current hypertension and in-service disease or injury. After consideration of all the evidence of record the Board finds that the weight of the evidence is against finding that service connection for hypertension is warranted. The Board concludes that service connection for hypertension is warranted as the Veteran's current hypertension was not caused by service. The Veteran's reports of the onset of his hypertension in-service warrant low credible and probative weight as they are not consistent with STRs. While the Veteran reports that his current hypertension is related to service, the record does not reflect that he has the requisite training or expertise to offer a medical opinion linking a current disability to service decades earlier and as such the Veteran is not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board finds that the medical evidence is more probative and credible than the lay opinions of record. The competent medical evidence including the May 2016 VA examination and January 2020 opinion are entitled to significant probative weight. The May 2016 VA examiner found that the Veteran's STRs does not support a diagnosis of hypertension in-service. In addition, the January 2020 VA opinion examiner noted that it is less likely than not that the current Veteran's hypertension was incurred in or caused by an instance of high blood pressure during service. The examiner noted a review of the Veteran's treatment records, and such are silent for evaluations, diagnoses and/or treatment for hypertension. The examiner found that it is less likely than not that the Veteran's current hypertension arose during service in March 1990. The examiner noted that the Veteran's elevated blood pressure, during that time was due to the symptoms of viral illness he was diagnosed with, and after treatment with medications and bedrest, the Veteran's blood pressure returned to normal. The examiner noted that the Veteran's physical exam and diagnostic studies do not reveal any undiagnosed illnesses or diagnosed medically unexplained chronic multi symptoms illness. The examiner noted that the Veteran's claimed conditions are attributable to a known clearly defined diagnosis of hypertension that has not been shown to have sufficient evidence of an associated with Gulf War service as shown above. The examiner noted that the Veteran's claimed conditions are attributable to a known clearly defined diagnosis that has not been shown to have sufficient evidence of an association with Gulf War service as shown above. The examiner noted that there is no credible medical authority, peer reviewed study, or DoD/VA directive that has established a link between Southwest Asia service and hypertension. The Veteran does not report any history or symptoms consistent with any medically unexplained chronic multi symptom illness which have been shown to have sufficient evidence of an association as described above. As such the examiner found that it is less likely than not that the Veteran's hypertension was incurred in or caused by service. The Board finds that direct service connection is not warranted as the Veteran's hypertension was not onset in or caused by service. The Board notes that the STRs note in March 1990 and instance of elevated blood pressure, which resolved with rest, medication and treatment. The Board has considered the Veteran's lay statements however, the Board give more probative weight to the competent medical evidence especially the May 2016 and January 2020 VA examination and opinion. As such the Board finds that the Veteran's current hypertension is less likely than not related to active service. As to presumptive service connection the Veteran's hypertension did not manifest until many years post-service. The Board concludes that while the Veteran has hypertension, which falls within a chronic disease under 38 U.S.C. § 1101 (3)/38 C.F.R. § 3.309(a), however such was not chronic in service nor did these manifest to a compensable degree in service or within the presumptive period, and continuity of symptomatology is not established. The Veteran's hypertension was not noted during service or within one year of separation. See Walker, 708 F.3d 1331. STRs note an instance of elevated blood pressure in March 1990. Service records do not support an onset of the Veteran's hypertension in active service. Service records note an instance of elevated blood pressure in-service, however, follow up treatment noted no instances of elevated blood pressure readings and no instance of treatment for hypertension including medication management. Based on the probative evidence of record the Board finds that the Veteran's hypertension did not manifest within the one-year period after service and service connection is not warranted on a presumptive basis. Private treatment records note hypertension was diagnosed in 2005, which is 10 years after his separation from service in 1995. In addition, in weighing the evidence of record the Board finds the competent and credible evidence of record is against finding continuity of symptomatology. As a result, service connection based on continuity of symptomology is not warranted. In addition, although the Veteran served in Southwest Asia during the applicable time period, he cannot establish service connection for an undiagnosed illness under 38 C.F.R. § 3.317, because while there is an indication of hypertension, as noted above the claimed condition has not been shown to be undiagnosed or part of a medically unexplained chronic multi symptom illness. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for hypertension. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 5557 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. REASONS FOR REMAND 1. Entitlement to service connection for a low back disability The Veteran contends that service connection is warranted for his current low back disability. The Board finds that additional development is warranted. The Veteran contends that his current low back disability is related to service. The Veteran reports that he injured his back while serving in Southwest Asia and ongoing physical training and combat readiness training resulted in injuries. The Veteran was afforded a VA examination in May 2016. The examiner noted a lumbosacral strain and degenerative arthritis. The examiner found that it is less likely than not that the Veteran's current low back condition is proximately due to or caused by military service, noting no documentation of low back problems. However, the examiner failed to fully consider the Veteran's lay contentions reporting an in-service injury to his low back while stationed in Southwest Asia, and his ongoing low back symptomology that began in-service and has continued since that time. Further, the examiner failed to fully address direct and presumptive service connection. As such a remand is warranted for a supplemental VA examination. 2. Entitlement to an increased initial evaluation in excess of 30 percent for PTSD 3. Entitlement to a TDIU The Veteran contends that an increased rating is warranted for his service-connected PTSD. During the course of the appeal the Veteran contends a worsening of his symptoms and that he recently had to resign from his job due to difficulty understanding complex commands and impairment of his short- and long-term memory. Additionally, the Veteran reports increased feelings of depression and disturbances in his mood and motivation. As such the Board finds that a remand is warranted for an updated VA examination. Next, the Veteran has raised the issue that he has been unable to work due to his service-connected PTSD. Further, the Veteran reports that during the appeal period he was forced to leave his employment due to worsening and associated PTSD symptomology. A claim for an increased rating may encompass a claim for entitlement to a TDIU. Rice v. Shinseki, 22 Vet. App. 447. As such the Board finds the issue of TDIU has been raised by the record and is added to the appeal. Further, the Board finds that because a decision on the remanded issue of entitlement to an increased rating for PTSD could significantly impact a decision on the issue of a TDIU, and as such the issues are inextricably intertwined. A remand of the claim for TDIU is required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's current low back disability whether: (a.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's current low back disability was caused by an in-service injury, event or disease? (b.) Is it at least as likely as not (a 50 percent probability or greater) that the Veteran's low back arthritis (1) began during active service, (2) manifested within the applicable presumptive period after discharge from service, or (3) was noted during service with continuity of the same symptomology since service? Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The Board notes the Veteran served in Southwest Asia during the applicable time period. Attention is invited to the VA examination in May 2016 noting that the examiner found that it is less likely than not that the Veteran's current low back condition is proximately due to or caused by military service noted no documentation with regard to low back problems. In addition, attention is invited to the Veteran's lay contentions reporting an in-service injury to his low back while stationed in Southwest Asia, and his ongoing low back symptomology that began in-service and has continued since that time. Further, the Veteran contends that in-service physical training (PT) and combat readiness training resulted in his current low back disability. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected PTSD. 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. The examiner must attempt to elicit information regarding the severity, frequency, and duration of symptoms. To the extent possible, the examiner should identify any symptoms and social and occupational impairment due to his service-connected PTSD alone. Review of the entire claims file is required. The examiner must provide a complete rationale for all findings and opinions, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Attention is invited to the Veteran's lay statements including contentions of a worsening of his symptoms and that he recently had to resign from his job due to difficulty understanding complex commands and impairment of his short- and long-term memory. Additionally, the Veteran reports increased feelings of depression and disturbances in his mood and motivation. (continued next page) 3. Provide the Veteran with appropriate notice regarding the TDIU claim and request that he complete VA Form 21-8940, Veteran's Application for Increased Compensation Based on Unemployability. Ask the Veteran to submit any additional evidence in support of a TDIU claim, to specifically include information on his work, history, salary and educational history. Then readjudicate the remanded TDIU issue. J.W. FRANCIS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.R. Kardian, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.