Citation Nr: 22015200 Decision Date: 03/16/22 Archive Date: 03/16/22 DOCKET NO. 09-44 730 DATE: March 16, 2022 ORDER An initial rating of 70 percent, but no higher, posttraumatic stress disorder (PTSD) with traumatic brain injury (TBI), for accrued benefits purposes, is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to service connection for a bilateral knee disability, for accrued benefits purposes, for accrued benefits purposes, is denied. Entitlement to service connection for residuals of a right leg infection (right leg disability), for accrued benefits purposes, for accrued benefits purposes, is denied. Entitlement to service connection for a right shoulder disability, for accrued benefits purposes, for accrued benefits purposes, is denied. Entitlement to service connection for a jaw disability, for accrued benefits purposes, for accrued benefits purposes, is denied. Entitlement to service connection for residuals of a buttocks injury (bilateral gluteal muscle disability), for accrued benefits purposes, for accrued benefits purposes, is denied. Entitlement to service connection for a neck disability, for accrued benefits purposes, for accrued benefits purposes, is denied. FINDINGS OF FACT 1. The evidence of record persuasively shows that the severity, frequency, and duration of the Veteran's PTSD and TBI symptoms more closely approximated occupational and social impairment with deficiencies in most areas. 2. The evidence of record persuasively weighs against finding that the Veteran had a bilateral knee disability that was manifest during service or for many years thereafter, and the Veteran's bilateral knee disability was not otherwise etiologically related to his active service. 3. The evidence of record persuasively weighs against finding that the Veteran had a diagnosed right leg disability. 4. The evidence of record persuasively weighs against finding that the Veteran had a diagnosed right shoulder disability at any time during or approximate to the pendency of the claim. 5. The evidence of record persuasively weighs against finding that the Veteran had a diagnosed jaw disability at any time during or approximate to the pendency of the claim. 6. The evidence of record persuasively weighs against finding that the Veteran had a diagnosed bilateral gluteal muscle disability at any time during or approximate to the pendency of the claim. 7. The evidence of record persuasively weighs against finding that the Veteran had a diagnosed neck disability at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. For accrued benefits or substitution purposes, an initial rating of 70 percent, but no higher, is warranted for PTSD with TBI. 38 U.S.C. § 1155; 38 C.F.R. § 4.130, Diagnostic Code 8045-9411. 2. For accrued benefits or substitution purposes, the criteria for entitlement to service connection for a bilateral knee disability are not met. 38 U.S.C. §§ 1110, 1111, 1131, 1132, 5103(a), 5103A; 38 C.F.R. §§ 3.159, 3.303, 3.304. 3. For accrued benefits or substitution purposes, the criteria for entitlement to service connection for a right leg disability are not met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 4. For accrued benefits or substitution purposes, the criteria for entitlement to service connection for a right shoulder disability are not met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 5. For accrued benefits or substitution purposes, the criteria for entitlement to service connection for a jaw disability are not met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 6. For accrued benefits or substitution purposes, the criteria for entitlement to service connection for a bilateral gluteal muscle disability are not met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 7. For accrued benefits or substitution purposes, the criteria for entitlement to service connection for a neck disability are not met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Marines Corps from January 1967 to September 1969. His decorations for his active duty service include a Combat Action Ribbon. The Veteran died in June 2011. VA substituted the Appellant, the Veteran's widow, in September 2012. These matters are on appeal from a June 2008 rating decision. In August 2018 and December 2020, these matters and a claim of entitlement to service connection for bronchitis were remanded by the Board for further development. The claims of entitlement to service connection for osteoarthritis and hysterectomy are ready for adjudication. The claim for service connection for bronchitis was granted in a May 2021 Decision Review Officer (DRO) decision. The Veteran did not disagree with the disability evaluation or the effective date assigned. Therefore, this matter is no longer considered to be in appellate status. In August 2016, these matters and a claim of entitlement to service connection for a head injury, were remanded by the Board for further development, to include requesting outstanding private hospital records, records from the Social Security Administration (SSA) records, and etiological opinions. VA medical opinions were obtained in February and May 2017. However, in a September 2016 response the SSA indicated that the requested records did not exist. Regarding the private hospital records, the Appellant failed to provide the necessary authorization to obtain those records. Accordingly, the Board finds that the evidentiary development complies with the prior remand directives and the claims are ready for adjudication. See Stegall v. West, 11 Vet. App. 268 (1998). The claim for service connection for a head injury (TBI) was granted in a July 2020 rating decision. The Appellant did not disagree with the disability evaluation or the effective date assigned. Therefore, this matter is no longer considered to be in appellate status. Increased Rating Claim Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities. Separate diagnostic codes identify the various disabilities, which are based, as far as practically can be determined, on average impairment in earning capacity. 38 U.S.C. § 1155 (2012); 38 C.F.R. Part 4. When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the Veteran's favor. 38 C.F.R. § 4.3. In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances. 38 C.F.R. § 4.21. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on facts found, a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119, 126 (1999). The evaluation of the same disability under various diagnoses, known as pyramiding, is generally to be avoided. 38 C.F.R. § 4.14. The critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the disabilities is duplicative or overlapping with the symptomatology of the other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). In this case, the Veteran has claimed that his service-connected PTSD with TBI is more severe than his currently assigned 50 percent evaluation. 38 C.F.R. § 4.130, Diagnostic Code 8045-9411. Hyphenated diagnostic codes are used when a rating under one code requires the use of an additional diagnostic code to identify the basis for the rating. 38 C.F.R. § 38 C.F.R. § 4.27. In the case at hand, Diagnostic Code 8045 applies to residuals of TBI, and the hyphenated diagnostic code directs that the disability be rated as PTSD (Diagnostic Code 9411). Under DC 8045, Residuals of TBI, there are 10 important facets of TBI related to cognitive impairment and subjective symptoms with criteria for levels of impairment for each facet, as appropriate, ranging from 0 to 3, and a 5th level, the highest level of impairment, labeled "total." However, not every facet has every level of severity. The Consciousness facet, for example, does not provide for an impairment level other than "total," since any level of impaired consciousness would be totally disabling. A 100 percent evaluation is warranted if ""total" is the level of evaluation for one or more facets. If no facet is evaluated as "total," assign of the overall percentage evaluation is based on the level of the highest facet as follows: 0 = 0 percent; 1 = 10 percent; 2 = 40 percent; and 3 = 70 percent. 38 C.F.R. § 4.124a. Note 1 of DC 8045 explains that there may be an overlap of manifestations of conditions evaluated under the table titled "Evaluation of Cognitive Impairment and Other Residuals of TBI Not Otherwise Classified" with manifestations of a comorbid mental or neurologic or other physical disorder that can be separately evaluated under another diagnostic code. 38 C.F.R. § 4.124a. In such cases, no more than one evaluation may be assigned based on the same manifestations. Id. If the manifestations of two or more conditions cannot be clearly separated, a single evaluation will be assigned under whichever set of diagnostic criteria allows the better assessment of overall impaired functioning due to both conditions. Id. If the manifestations are clearly separable, a separate evaluation for each condition will be assigned. Id. Evaluations for various psychiatric disabilities are assigned pursuant to 38 C.F.R. § 4.130. Under the general rating formula for mental disorders, a 50 percent rating is assigned for occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, DC 9411. A rating of 70 percent is assigned where there is occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); and inability to establish and maintain effective relationships. A 100 percent schedular evaluation contemplates total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The list of symptoms under the rating criteria are meant to be examples of symptoms that would warrant the evaluation, but are not meant to be exhaustive. The Board need not find all or even some of the symptoms to award a specific evaluation. Mauerhan v. Principi, 16 Vet. App. 436, 442-3 (2002). On the other hand, if the evidence shows that a veteran suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. The United States Court of Appeals for the Federal Circuit (Federal Circuit) has embraced the Mauerhan Court's interpretation of the criteria for rating psychiatric disabilities. Sellers v. Principi, 372 F.3d 1318, 1326 (Fed. Cir. 2004). The U.S. Court of Appeals for the Federal Circuit (Federal Circuit) provided additional guidance in rating psychiatric disability. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Specifically, the Federal Circuit emphasized that the list of symptoms under a given rating is a nonexhaustive list, as indicated by the words "such as" that precede each list of symptoms. Id. at 2. It held that a veteran may only qualify for a given disability rating under § 4.130 by demonstrating the particular symptoms associated with that percentage or others of similar severity, frequency, and duration. Id. at 4. Other language in the decision indicates that the phrase "others of similar severity, frequency, and duration," can be thought of as symptoms of like kind to those listed in the regulation for a given disability rating. Id. at 2. When it is not possible to separate the effects of a nonservice-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). Turning to the evidence, VA treatment records show that the Veteran first presented for VA medical treatment in September 2007 at which time the Veteran stated that he had a short fuse and great anger. In a March 2008 statement the Veteran stated that he was on his fourth marriage and had a total of nine kids none of whom wanted anything to do with him. He did have a relationship with his stepchildren. He had been drinking since his return from service. He had night sweats and nightmares during which he accidentally hit his spouse. He had gone to jail and prison many times for the use of guns. At his initial medical appointment, he was distraught and very angry. The Veteran stated that he wanted to kill everyone in sight. He did not care about anything or anyone other than his wife. On March 2008 VA PTSD examination the Veteran presented with a history of a service-related head injury. Post service, the Veteran stated that he had continual problems with anger for decades. He stated that he fought with both private citizens and the police and had been in numerous county jails. However, no legal issues were pending at the time of the examination. Regarding post-service employment, the Veteran worked in welding, steel fabrication, gold mines, concrete, farming, roofing, and plumbing. His longest position lasted ten years. He left his last job of three years after he lost his license due to seizures. Regarding his family, the Veteran was on his fourth marriage. He had three kids from each previous marriage with whom he had no contact. The Veteran stated that his fourth wife was very supportive. Regarding leisure pursuits, he used to enjoy fishing, hunting, and camping but had not done any of those activities in thirty years. He drank moderately until last October when he bit his tongue in a motor vehicle accident and resumed drinking due to the pain. On mental status examination, he presented with a neat Marine-style haircut, mustache, and goatee. He was alert with good eye contact and normal speech. He was euthymic with wide affect and engaged in some humor. Thinking was linear with no delusional content or suicidal or homicidal ideations. He was oriented in all spheres with memory grossly intact. There were no anxiety symptoms or impairment of impulse control during the examination. The assessment was PTSD, chronic with a GAF of 50. The examiner noted that the Veteran stated that he had a bad temper for 40 years, but was unaware of it. He had combat-related nightmares three to four times a week during which he would wake up in a sweat, pounding and stabbing, which caused his wife to jump out of bed. The Veteran had a thirty-year history of diminished activities and estrangement from others. The examiner opined that the Veteran's impairment of social and interpersonal functioning was severe. His symptoms had improved over the past few months with current medications, but he required ongoing treatment to maintain his improved level of functioning. The examiner opined that alcohol dependence had been a problem in the past, but was likely secondary to his PTSD. VA treatment records include a September 2009 report which indicates an assessment of PTSD and a notation that the Veteran apparently could not be left alone, but was fine when his wife was around. He took his medication and went to work, but could have bouts of extreme heavy drinking with falls. In a November 2009 statement, the Veteran stated that he experienced persistent hallucinations (nightmares/night sweats) grossly inappropriate behavior, persistent danger of hurting others, personal hygiene, which support the assignment of a 100 percent rating; had difficulty with family relations, judgement, thinking, mood, OCD, impaired impulse control, unprovoked irritability with periods of violence, neglect of personal appearance, and an inability to establish and maintain effective relationships, which support the assignment of a 70 percent rating; short-term memory loss, impaired judgement and mood, and difficulty in establishing and maintaining effective work and social relationships, which support the assigment of a 50 percent rating; and suspiciousness and chronic sleep impairment, which support the assignment of a 30 percent rating. Additional VA treatment records include a February 2011 primary care outpatient report which indicates an assessment of PTSD/anxiety piece which had worsened. He also had problems with impulse control likely due to damage to his frontal lobe and alcohol. Unfortunately, he would not see psychiatry. Applying the relevant criteria, the Board finds that the evidence of record persuasively shows that the Veteran is entitled to an initial disability evaluation of 70 percent for his PTSD and TBI. The evidence shows that the Veteran had impaired impulse control manifested by bouts of extreme alcohol consumption which caused falls. In this regard, although the Veteran is not service-connected for an alcohol abuse disorder, the Board finds that it is not possible to separate the effects of the nonservice-connected alcohol abuse disorder, mainly the Veteran's impaired impulse control, from his service-connected PTSD with TBI. See Mittleider, supra. The Veteran also had an inability to establish and maintain effective relationships based on his history of three failed marriages and a lack of any relationship with his biological children. The Board, however, finds that the evidence weighs persuasively against a finding that symptoms of the Veteran's PTSD/TBI more closely approximated total occupational and social impairment required for the assignment of a 100 percent rating. In an October 2020 statement, the Appellant stated that a 100 percent rating was warranted based on the death of the Veteran's brother during service and violent nature when he drank. However, the rating criteria do not allow for the assignment of a higher rating based on the unfortunate passing of the Veteran's brother. Moreover, the impaired impulse control described by the Appellant as a violent nature when the Veteran consumed alcohol, is contemplated by the 70 percent rating assigned herein. The Board has also considered the November 2009 statement in which the Veteran claimed to have experienced persistent hallucinations (nightmares/night sweats) grossly inappropriate behavior, persistent danger of hurting others, and issues maintaining personal hygiene. However, there simply was no evidence of persistent delusions or hallucinations; persistent danger of hurting self or others; or difficulty maintaining personal hygiene. In this regard, on 2008 VA examination the Veteran was described as having a neat Marine-style haircut, mustache, and goatee. There was no evidence of delusional content or suicidal or homicidal ideations on examination. The Board fully recognizes that the listed symptoms for a 100 percent schedular rating are not all encompassing, and their presence is not necessarily determinative. However, the Veteran's symptoms must cause the occupational and social impairment in the referenced areas. See Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013). Total occupational and social impairment due to his psychiatric disability, as contemplated by the rating criteria, is simply not shown or even approximated. It is important for the Appellant to understand that a disability evaluation of 70 percent would cause the Veteran many problems and that this fact is not in dispute. If there were no problems associated with his disability during this period, there would be no basis for a compensable evaluation (zero), let alone a 70 percent evaluation. The Veteran's statements made during the VA examination in many respects support a 70% evaluation, not a 100% finding. The critical question in this case, however, is whether the problems the Veteran and Appellant believably cited meet an even higher, 100 percent, level under the rating criteria. For reasons cited above, they do not, for any part of the rating period. The Board has also considered whether an inferred claim for a total disability rating based on individual unemployability (TDIU) under Rice v. Shinseki, 22 Vet. App. 447 (2009) has been raised. However, the Appellant does not contend, and the evidence does not show, that the Veteran's PTSD with TBI rendered him unemployable. Specifically, in an August 2010 claim the Veteran stated that he was unemployable due to peripheral neuropathy. Thus, the Board finds that Rice is inapplicable since there is no evidence of unemployability due to the Veteran's PTSD with TBI. Finally, neither the Appellant nor her representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (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). Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303 (a). Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Pertinent to a claim for service connection, such a determination requires a finding of current disability that is related to an injury or disease in service. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). The requirement of a current disability is satisfied when the Veteran has a disability at the time he files his service connection claim or during the pendency of that claim, even if the disability resolves prior to the adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). However, when the record contains a recent diagnosis of disability prior to the Veteran's filing of a claim for benefits based on that disability, the report of the diagnosis is relevant evidence that the Board must address in determining whether a current disability existed at the time of the claim was filed or during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Under applicable regulation, the term "disability" means impairment in earning capacity resulting from diseases and injuries and their residual conditions. 38 C.F.R. § 4.1; see also Hunt v. Derwinski, 1 Vet. App. 49 (1990); Saunders v. Wilkie, 886 F.3d 1356, 1364-65 (Fed. Cir. 2018) (pain need not be diagnosed as connected to a current underlying condition to function as an impairment and pain alone can be considered a disability under 38 U.S.C. § 1110); see also Wait v. Wilkie, 33 Vet. App. 8, 17 (2020) (a veteran must show that his manifestations are of sufficient severity, duration, and frequency that they effect his ability to function under the ordinary conditions of daily life). The Veteran contends that he incurred right leg, right shoulder, bilateral knee, jaw, buttocks, head, and neck injuries during service in Vietnam when he was shot and stabbed and when his jeep was hit by a mortar. See March 2008 and November 2009 statements. In this regard, the Board finds that the Veteran's claimed injuries are consistent with the circumstances, conditions, and hardships of his combat service, and are credible. See 38 U.S.C. § 1154 (b). However, competent evidence of a current disability and of a link between the current disability and service is still required. 1. Bilateral knee disability The Appellant contends that the Veteran had a bilateral knee disability that is related to his service. The Veteran contended that he was shot and stabbed in each knee six times and also sustained injury during to his knees when his jeep was blown up by a land mine which caused injury to his knees. See October 2007 claim and March 2008 statement. He also claimed that he had arthritis in his knees. See November 2009 statement. The service treatment records (STRs) include a December 1966 enlistment examination which indicates normal clinical evaluation of the lower extremities, but a scar was noted on the left knee. The accompanying Report of Medical history indicates that the Veteran underwent a knee operation for a ruptured medial meniscus at age 17, but the knee was listed as "OK" and a full recovery was noted. The Report of Medical History also indicates a history of a trick or locked knee. However, because no knee disability was noted at enlistment, he is presumed sound. The remaining STRs are void of findings, complains, symptoms or any diagnosed left or right knee disability. Post service, VA treatment records indicate complaints of right knee instability and time. A problem list indicated a tear of medial cartilage or meniscus of knee as of December 2008. A February 2009 orthopedic surgery note indicates a complaint of a 40-year history of right knee pain with locking and instability. The impression was rule out medial compartment internal derangement. A March 2009 MRI of the right knee was unremarkable. A May 2009 orthopedic surgery note indicates that the Veteran sustained a shrapnel or bullet wound during service which was self-treated and did not become infected or affect deep structures. On April 2010 VA peripheral nerves examination the examiner noted that the Veteran stated that he was told that his right knee problem was really coming from the nerve damage rather than a right knee disability. In August 2016, the Board remanded the claims for an etiological opinion regarding the Veteran's bilateral knee disability. Pursuant to the Board's remand, in a February 2017 VA medical opinion a VA examiner opined that the Veteran's bilateral knee disability was less likely than not related to his service. In the rationale that examiner indicated that she reviewed the Veteran's prior complaints of bilateral knee pain he related to combat, including a vehicle accident and being shot and self-treating shrapnel wounds. He reported that he had bilateral knee pain since then. The examiner noted that the Veteran had left knee scars secondary to meniscal surgery prior to service, but was not having any difficulties at that time o of induction. The STRs were negative for complaints of knee issues. Post-service, the records showed a motor vehicle accident in 2006 and a right leg injury as a result of that accident, although no specifics were offered with respect to the injury and no X-rays to the area were seen in the records. The examiner noted substantial knee complaints in 2008 and 2009, but X-ray examinations did not show any evidence of any degenerative changes or other findings that would suggest chronic trauma. The examiner also noted the Veteran's post-service positions in machinery and fabrication, in addition to employment as a welder and mechanic. These occupations are considered moderately physically strenuous and the Veteran did not have any work restrictions seen on available records with respect to the knees. The examiner stated that the Veteran was seen by rheumatology to evaluate the possibility that the knee pain was due to psoriatic arthritis, but review of the notes indicates that the rheumatologist opined that the knee pain was not psoriatic in nature. The examiner stated that while it is not contested that the Veteran may have sustained some knee strained to the knees in service, there is no evidence to suggest that the injuries he sustained were chronic or disabling, since no mention was made of any knee issue until 2006, although that reference was made as part of history taken following a hospitalization. Moreover, even though the Veteran reported shrapnel wounds plain X-rays did not demonstrate any residual shrapnel and the Veteran reported self-treatment which suggests that the shrapnel was very superficial and would not have been expected to result in any long term knee problem. The examiner opined that the bilateral knee pain the Veteran reported as having sustained during combat is not contested, but determined that the evidence provided no support for a chronic or disabling injury. His complaints regarding a 40-year history of chronic knee pain were not supported by the record which provided no evidence of an ongoing disabling disability. The Board finds that the claims must be denied. The Board is persuaded that the evidence does not support a finding that the Veteran had any bilateral knee disability that was incurred in or aggravated by his service. Moreover, the Veteran's STRs are void of any complaint or diagnosis of any heart disability. Post-service, medical records do not reflect or reference any history of a heart disability for over four decades after discharge from active service. More importantly, there is no competent medical evidence to show that the Veteran has any bilateral knee disability that is related to his service. The mere absence of medical records does not contradict a Veteran's statements about his symptom history. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, if it is determined based upon reliable evidence that there was an extended period of time after service without any manifestations of the claimed condition, then that tends to weigh against a finding of a connection between the disability and service. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); see also Horn v. Shinseki, 25 Vet. App. 231, 240 n.7 (2012). The Board finds in this case that the lack of evidence of a bilateral knee disability during service coupled with the fact this diagnosis was not made until more than three decades post-service, is sufficient to rebut a finding of service incurrence. In this case, the earliest post-service medical evidence of a knee disability was in 2006 according to the VA examiner, which is at least 37 years after service. Moreover, to the extent that the Appellant believes that the Veteran's bilateral knee disability was related to his service, the Board finds that her statements are credible. However, this contention is afforded little probative value in that they conflict with the absence of treatment evidence for over three decades. Finally, the evidence of record persuasively weighs against finding that the Veteran had any bilateral knee disability that was related to his service. 2. Right leg disability The Appellant contends that the Veteran had a right leg infection that was related to being shot, stabbed, and a jeep accident during service. See October 2007 claim. However, the STRs are void of findings, complaints, symptoms, or any diagnosis related to right leg infection or disability. Post-service, the record does not contain any medical records or evidence of any diagnosed right leg infection. Private treatment records indicate a leg injury status post motor vehicle accident, but do not specify which leg. The Board finds that the claim must be denied. The evidence of record persuasively weighs against finding that the Veteran had a diagnosed right leg infection or disability during or after the Veteran's service. Accordingly, service connection is denied. See Brammer, supra; see also McClain, supra; Romanowsky, supra; Saunders, supra. To the extent that the Veteran complained of right leg pain, there is no indication that any subjective complaints resulted in functional impairment of earning capacity. See Hunt, supra; Saunders, supra. Consequently, the Board finds that, at no time during the pendency of the claim did the Veteran have a current diagnosis of any right leg infection or disability and the record does not contain a recent diagnosis of disability prior to the Veteran's filing of a claim. Therefore, service connection for a right leg disability is not warranted. 3. Right shoulder disability The Appellant contends that the Veteran had a right shoulder disability that was related to being shot, stabbed, and a jeep accident during his service. However, the STRs are void of findings, complaints, symptoms, or any diagnosis related to right shoulder disability. Post-service, the record does not contain any medical records or evidence of any diagnosed right shoulder disability. The Board finds that the claim must be denied. The evidence of record persuasively weighs against finding that the Veteran had any diagnosed right shoulder disability during or since the Veteran's service. Accordingly, service connection is denied. See Brammer, supra; see also McClain, supra; Romanowsky, supra; Saunders, supra. To the extent that the Veteran complained of right shoulder pain, there is no indication that any subjective complaints resulted in functional impairment of earning capacity. See Hunt, supra; Saunders, supra. Consequently, the Board finds that, at no time during the pendency of the claim did the Veteran have a current diagnosis of any right shoulder disability and the record does not contain a recent diagnosis of disability prior to the Veteran's filing of a claim. Therefore, service connection for a right shoulder disability is not warranted. 4. Jaw disability The Appellant contends that the Veteran had a jaw disability that was related to a jeep accident during service. However, the STRs are void of findings, complaints, symptoms, or any diagnosis related to a jaw disability. Post-service, the record does not contain any medical records or evidence of any diagnosed jaw disability. The Board finds that the claim must be denied. The evidence of record persuasively weighs against finding that the Veteran had any diagnosed buttocks disability during or since the Veteran's service. Accordingly, service connection is denied. See Brammer, supra; see also McClain, supra; Romanowsky, supra; Saunders, supra. To the extent that the Veteran complained of jaw pain, there is no indication that any subjective complaints resulted in functional impairment of earning capacity. See Hunt, supra; Saunders, supra. Consequently, the Board finds that, at no time during the pendency of the claim did the Veteran have a current diagnosis of any jaw disability and the record does not contain a recent diagnosis of disability prior to the Veteran's filing of a claim. Therefore, service connection for a jaw disability is not warranted. 5. Bilateral gluteal muscle disability The Appellant contends that the Veteran had a buttocks disability that was related to being shot, stabbed, and a jeep accident during service. However, the STRs are void of findings, complaints, symptoms, or any diagnosis related to buttock disability. Post-service, the record does not contain any medical records or evidence of any diagnosed buttocks disability. The Board finds that the claim must be denied. The evidence of record persuasively weighs against finding that the Veteran had any diagnosed buttocks disability during or since the Veteran's service. Accordingly, service connection is denied. See Brammer, supra; see also McClain, supra; Romanowsky, supra; Saunders, supra. To the extent that the Veteran complained of buttock pain, there is no indication that any subjective complaints resulted in functional impairment of earning capacity. See Hunt, supra; Saunders, supra. Consequently, the Board finds that, at no time during the pendency of the claim did the Veteran have a current diagnosis of any buttock disability and the record does not contain a recent diagnosis of disability prior to the Veteran's filing of a claim. Therefore, service connection for a bilateral gluteal muscle disability is not warranted. 6. Neck disability The Appellant contends that the Veteran had a neck disability that was related to being shot, stabbed, and a jeep accident during service. However, the STRs are void of findings, complaints, symptoms, or any diagnosis related to a neck disability. Post-service, the record does not contain any medical records or evidence of any diagnosed neck disability. The Board finds that the claim must be denied. The evidence of record persuasively weighs against finding that the Veteran had any diagnosed neck disability during or since the Veteran's service. Accordingly, service connection is denied. See Brammer, supra; see also McClain, supra; Romanowsky, supra; Saunders, supra. To the extent that the Veteran complained of a neck disability, there is no indication that any subjective complaints resulted in functional impairment of earning capacity. See Hunt, supra; Saunders, supra. Consequently, the Board finds that, at no time during the pendency of the claim did the Veteran have a current diagnosis of any neck disability and the record does not contain a recent diagnosis of disability prior to the Veteran's filing of a claim. Therefore, service connection for a neck disability is not warranted. Additional considerations The Board has taken the contention that the Veteran's bilateral knee disability was caused by service and that he had disabilities of the right shoulder, right leg, jaw, buttocks, and neck, seriously. Although the Appellant might believe that the Veteran's bilateral knee disability was related to his service and that he had disabilities of the right shoulder, right leg, jaw, buttocks, and neck, the Board has closely reviewed the medical and lay evidence in the Veteran's claims file and finds no evidence that may serve as a medical nexus between the Veteran's and his claimed bilateral knee disabilities or any evidence that he had disabilities of the right shoulder, right leg, jaw, buttocks, and neck. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issues in this case, the etiology of the Veteran's bilateral knee disability and the existence of diagnosed disabilities of the right shoulder, right leg, jaw, buttocks, and neck, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). In light of the above, the Board is not persuaded that the evidence supports granting service connection for bilateral knee, right shoulder, right leg, jaw, buttocks, and neck disabilities. As such, these claims are denied. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Adams, 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.