Citation Nr: 22017777 Decision Date: 03/26/22 Archive Date: 03/26/22 DOCKET NO. 17-13 632 DATE: March 26, 2022 ORDER The appeal as to the issue of entitlement to service connection for a right groin strain is dismissed. The appeal as to the issue of entitlement to service connection for a left groin strain is dismissed. The appeal as to the issue of entitlement to service connection for a nail puncture of the left thigh is dismissed. The appeal as to the issue of entitlement to service connection for a right knee disability is dismissed. The appeal as to the issue of entitlement to service connection for a left ankle disability is dismissed. The appeal as to the issue of entitlement to service connection for a right heel disability, to include right heel pain, is dismissed. The appeal as to the issue of entitlement to service connection for a left shoulder (variously diagnosed as rotator cuff, pec injury) disability is dismissed. The appeal as to the issue of entitlement to service connection for forehead laceration is dismissed. The appeal as to the issue of entitlement to service connection for residuals of a puncture wound of the right thumb is dismissed. The appeal as to the issue of entitlement to service connection for cystic acne is dismissed. The appeal as to the issue of entitlement to service connection for a right elbow disability is dismissed. The appeal as to the issue of entitlement to service connection for a left elbow disability is dismissed. The appeal as to the issue of entitlement to service connection for a right arm (variously claimed as injury, tendon tear) disability is dismissed. The appeal as to the issue of entitlement to service connection for residuals of a left arm injury is dismissed. The appeal as to the issue of entitlement to service connection for residuals of eye injuries (claimed variously as Hibiclens in eye, chemical burn, paint stripper in eye, silver in eye) is dismissed. The appeal as to the issue of entitlement to service connection for decreased near vision (presbyopia) is dismissed. The appeal as to the issue of entitlement to service connection for residuals of a right and left rib injury (fracture) is dismissed. The appeal as to the issue of entitlement to service connection for residuals of a needle stick is dismissed. The appeal as to the issue of entitlement to service connection for a left leg disability is dismissed. The appeal as to the issue of entitlement to service connection for numbness in the fingers of the right hand is dismissed. The appeal as to the issue of entitlement to service connection for numbness in the fingers of the left hand is dismissed. Service connection for a low back strain is granted. Service connection for residuals of a coccygeal injury is granted. Service connection for a cervical spine strain is granted. Service connection for rosacea is granted. REMANDED Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a left heel disability, to include left heel pain, is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a sinus disability is remanded. Entitlement to service connection for residuals of dental trauma is remanded. Entitlement to an initial disability rating greater than 20 percent for service-connected gout. Entitlement to an initial compensable disability rating for service-connected kidney stones. FINDINGS OF FACT 1. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for a right groin strain. 2. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for a left groin strain. 3. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for a nail puncture of the left thigh. 4. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for a right knee disability. 5. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for a left ankle disability. 6. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for a right heel disability, to include right heel pain. 7. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for a left shoulder (variously diagnosed as rotator cuff, pec injury) disability. 8. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for forehead laceration. 9. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for residuals of a puncture wound of the right thumb. 10. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for cystic acne. 11. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for a right elbow disability. 12. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for a left elbow disability. 13. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for a right arm (variously claimed as injury, tendon tear) disability. 14. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for residuals of a left arm injury. 15. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for residuals of eye injuries (claimed variously as Hibiclens in eye, chemical burn, paint stripper in eye, silver in eye). 16. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for decreased near vision (presbyopia). 17. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for residuals of a right and left rib injury (fracture). 18. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for residuals of a needle stick. 19. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for a left leg disability. 20. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for numbness in the fingers of the right hand. 21. During the July 2021 Board hearing, the appellant withdrew his claim of entitlement to service connection for numbness in the fingers of the left hand. 22. The Veteran's low back strain began during active service. 23. The Veteran's residuals of a coccygeal injury began during active service. 24. The Veteran's cervical spine strain began during active service. 25. The Veteran's rosacea began during active service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for a right groin strain. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 2. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for a left groin strain. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 3. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for a nail puncture of the left thigh. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 4. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for a right knee disability. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 5. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for a left ankle disability. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 6. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for a right heel disability, to include right heel pain. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 7. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for a left shoulder (variously diagnosed as rotator cuff, pec injury) disability. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 8. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for forehead laceration. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 9. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for residuals of a puncture wound of the right thumb. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 10. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for cystic acne. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 11. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for a right elbow disability. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 12. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for a left elbow disability. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 13. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for a right arm (variously claimed as injury, tendon tear) disability. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 14. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for residuals of a left arm injury. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 15. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for residuals of eye injuries (claimed variously as Hibiclens in eye, chemical burn, paint stripper in eye, silver in eye). 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 16. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for decreased near vision (presbyopia). 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 17. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for residuals of a right and left rib injury (fracture). 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 18. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for residuals of a needle stick. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 19. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for a left leg disability. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 20. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for numbness in the fingers of the right hand. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 21. The criteria for withdrawal of an appeal by the appellant have been met as to the issue of entitlement to service connection for numbness in the fingers of the left hand. 38 U.S.C. § 7105; 38 C.F.R. § 19.55. 22. The criteria for service connection for a low back strain are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 23. The criteria for service connection for residuals of a coccygeal injury are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 24. The criteria for service connection for a cervical strain are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 25. The criteria for service connection for rosacea are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1983 to December 2009, to include service in the Southwest Asia Theater of Operations. His decorations include the Air Force Combat Action Medal. This case is before the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decisions of the Department of Veterans Affairs (VA), Regional Office (RO), in Atlanta, Georgia. In July 2021, the Veteran testified at a personal hearing over which the undersigned Veterans Law Judge presided. A transcript of the hearing is of record. During the July 2021 Board hearing, it was determined that the issues of an increased disability rating for the service-connected gout and kidney stones are properly on appeal before the Board, even thought they were not clearly noted in the March 2017 Appeal To Board Of Veterans' Appeals (VA Form 9). It is also noted that the issues on appeal had included service connection for right heel pain, service connection for right heel disability, service connection for left heel pain, and service connection for left heel pain. A claimant may satisfy the requirement of reporting a disability by referring to a body part or system that is disabled or by describing symptoms of the disability. Brokowski v. Shinseki, 23 Vet. App. 79, 86-87 (2009); see also Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (when determining the scope of a claim, the Board must consider "the claimant description of the claim; the symptoms the claimant describes; and the information the claimant submits or that the Secretary obtains in support of that claim"). As such, the Board has recharacterized some of the issues on appeal so that all claimed symptoms are considered regardless of medical diagnosis, and to avoid unnecessary duplication of issues. Withdrawn Claims 1. Entitlement to service connection for a right groin strain. 2. Entitlement to service connection for a left groin strain. 3. Entitlement to service connection for a nail puncture of the left thigh. 4. Entitlement to service connection for a right knee disability. 5. Entitlement to service connection for a left ankle disability. 6. Entitlement to service connection for a right heel disability, to include right heel pain. 7. Entitlement to service connection for a left shoulder (variously diagnosed as rotator cuff, pec injury) disability. 8. Entitlement to service connection for forehead laceration. 9. Entitlement to service connection for residuals of a puncture wound of the right thumb. 10. Entitlement to service connection for cystic acne. 11. Entitlement to service connection for a right elbow disability. 12. Entitlement to service connection for a left elbow disability. 13. Entitlement to service connection for a right arm (variously claimed as injury, tendon tear) disability. 14. Entitlement to service connection for residuals of a left arm injury. 15. Entitlement to service connection for residuals of eye injuries (claimed variously as Hibiclens in eye, chemical burn, paint stripper in eye, silver in eye). 16. Entitlement to service connection for decreased near vision (presbyopia). 17. Entitlement to service connection for residuals of a right and left rib injury (fracture). 18. Entitlement to service connection for residuals of a needle stick. 19. Entitlement to service connection for a left leg disability. 20. Entitlement to service connection for numbness in the fingers of the right hand. 21. Entitlement to service connection for numbness in the fingers of the left hand. The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 19.55. Withdrawal may be made by the appellant or by his authorized representative. 38 C.F.R. § 19.55. A withdrawal must be explicit, unambiguous, and done with a full understanding of the consequences of such action by the appellant and the subsequent Board dismissal must include findings as to all three elements. See Acree v. O'Rourke, 891 F.3d 1009 (Fed. Cir. 2018). In the present case, prior to the July 2021 Board hearing, the Veteran, his representative, and the undersigned discussed the issues of service connection for a right groin strain; left groin strain; nail puncture of the left thigh; right knee disability; left ankle disability; right heel disability, to include right heel pain; left shoulder (variously diagnosed as rotator cuff, pec injury) disability; forehead laceration; puncture wound of the right thumb; cystic acne; right elbow disability; left elbow disability; right arm (variously claimed as injury, tendon tear) disability; left arm injury; eye injuries (claimed variously as Hibiclens in eye, chemical burn, paint stripper in eye, silver in eye); decreased near vision (presbyopia); right and left rib injuries (fracture); residuals of a needle stick; left leg disability; numbness in the fingers of the right hand; and numbness in the fingers of the left hand. The Veteran affirmed that he was requesting a withdrawal as to the issues. During the hearing, the undersigned clearly discussed the issues to be withdrawn, and the Veteran affirmed that he did not wish to proceed with the appeal on those issues. Based on the pre-hearing discussion and the hearing testimony, the Veteran explicitly, unambiguously, and with a full understanding of the consequences of such action, withdrew the claims. Hence, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board may not review the withdrawn appeals, and they are dismissed. Service Connection Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. In order to prevail on the issue of service connection for a disability, there must be evidence of a current disability; evidence of in-service occurrence or aggravation of a disease or injury; and medical evidence, or in certain circumstances, lay evidence, of a nexus between an in-service injury or disease and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Service connection for certain chronic diseases, such as arthritis, may also be established based upon a legal "presumption" by showing that it manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309. The option of establishing service connection through a demonstration of continuity of symptomatology rather than through a finding of nexus is specifically limited to the chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For Veterans with service in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. Under that section, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active service in the Southwest Asia theater of operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2026. See 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117; 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A medically unexplained chronic multi symptom illness is one defined by a cluster of signs or symptoms and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi symptom illness. A "medically unexplained chronic multi symptom 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 multi symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(ii). "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). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of this section, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Presumptive service connection is also warranted for certain infectious diseases; however, they are not pertinent to the issues currently before the Board. See 38 C.F.R. § 3.317(c)(2). If the Veteran engaged in combat with the enemy, and it is claimed that a disease or injury was incurred in such combat, VA shall accept as sufficient proof of service connection satisfactory lay or other evidence of service incurrence, if the lay or other evidence is consistent with the circumstances, conditions, or hardships of such service. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). To establish service connection, however, there must be medical evidence of a nexus between the current disability and the combat injury. See Dalton v. Nicholson, 21 Vet. App. 23 (2007); Libertine v. Brown, 9 Vet. App. 521, 523-24 (1996). In such cases, not only is the combat injury presumed, but so are the consequences of that injury at least in service. See Reeves v Shinseki, 682 F.3d 988 (Fed. Cir. 2012). It is noted that during the July 2021 Board hearing, the Veteran indicated that he had experience as both a dental assistant and a combat medic. This has been corroborated by the service personnel records. 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for residuals of a coccygeal injury. The Veteran asserts that he has low back and coccygeal disabilities that are manifested as a result of his period of active service. During the July 2021 Board hearing, he indicated that he was involved in a helicopter accident during combat service in Iraq. He described sitting on an ammunition can when the helicopter impacted with the ground, and that there was nothing to absorb the impact except for his back. He stated that an injury to his coccyx was documented in the service treatment records, but that other back symptoms had not been noted. He also indicated that he had been experienced progressively worse symptoms ever since. A United States Air Force Command Directed Investigation Board Report received in December 2021 confirms that the asserted helicopter accident occurred on July 3, 2005, at the Baghdad International Airport. It further identifies the Veteran as the Mishap Flight Engineer, and also notes that the Veteran sustained a bruised tailbone. It was noted that the aircraft fuselage aft of the main landing gear and forward of the tail wheel impacted a beam sustaining an estimated $6 million in damages. A US Air Force Mishap Report dated in July 2005 reiterates the foregoing, noting that the flight engineer sustained minor injuries, and the aircraft sustained major damage. A review of the Veteran's service treatment records reveals that he was treated for a low back muscle strain in December 1990. A physical therapy consultation report dated later in December 1990 that shows he was treated following a two week history of back pain incurred while playing racquetball; the diagnosis was low back pain with right spasms at T11-L4. In October 1991, he was treated for a mild back strain after slipping on a wet floor. In July 2005, following the helicopter accident, he was treated for a sacral contusion with a possible coccyx fracture. The Veteran's December 2009 retirement physical examination report shows that he was said to be in good health with no reported back pain. However, a report of medical assessment dated in December 2009 shows that the July 2005 low back injury was noted (hard landing with fractured coccyx and fractured teeth). It was indicated that the Veteran continued to experience intermittent pain with prolonged sitting and driving. There was no radiculopathy. X-rays of the low back were not conducted. Following service, a VA examination report dated in April 2013 shows that the Veteran provided a medical history of onset of low back pain in service consistent with that as set forth above. He described ongoing progressively worse symptoms with pain that would occasionally radiate to the lower extremities. The Veteran noted that he worked in construction, and that the work that he participated in exacerbated the symptoms. X-rays of the low back were not conducted. The diagnosis was (1) contusion of the coccyx, per record, resolved, no objective evidence of residuals, no functional limitations; (2) lumbar strain, per record, resolved, no objective evidence of residuals, no functional limitations; and (3) lumbar strain on this examination, not due to (1) or (2). The examiner indicated that a more precise diagnosis could not be rendered as there was no objective data to support a more definitive diagnosis. The examiner opined that the Veteran's back disability was less likely as not incurred in or caused by service; that lumbar spine strains and coccygeal contusions were generally self-limiting and resolved with proper treatment; and that there was no post-service evidence of a chronic condition. VA outpatient treatment records dated in June and July 2013 show that the Veteran was said to have a history of chronic lower back pain related to a helicopter crash in 2005. Chronic low back (to include coccygeal) pain was noted in August and October 2013, November 2015, and October 2016. It does not appear that X-rays of the low back were ever conducted. The evidence persuasively shows that, while X-rays of the low back have not been conducted, the Veteran has been variously diagnosed with low back strain and low back pain that radiates from the coccyx area to the lower extremities. As such, the evidence of record has established the existence of a current disability. Thus, the question becomes whether the current disability is related to active service. In this regard the Board has considered the April 2013 opinion of the VA examiner that concluded the in-service low back and coccyx disabilities had resolved, and that the Veteran's current symptoms were related to his post-service construction work. However, the VA examiner does not appear to give probative weight to the Veteran's separation report of medical assessment where it is indicated that four years following his helicopter accident, he continued to experience intermittent pain with prolonged sitting and driving. Moreover, the VA examiner, (a nurse practitioner) does not appear to consider the lay reports of the Veteran, who has some level of medical training as a dental assistant and a combat medic. Additionally, the VA examiner provided a conclusory statement that lumbar spine strains and coccygeal contusions were generally self-limiting and resolved with proper treatment, but did not provide support for the statement, nor evidence that "proper treatment" had been undertaken given that the Veteran had ongoing symptoms four years after the in-service injury. As such, the opinion is deemed to be of limited probative value. The other evidence of record, to include the testimony of the Veteran, is deemed competent and credible and entitled to probative weight, as it is internally consistent and consistent with other evidence of record, that shows he had several incidents of back treatment, along with the injuries related to the July 2005 helicopter accident, during service, and that he has had ongoing symptoms ever since. The Veteran's claims as to the onset and continuity of his low back and coccyx symptoms are consistent with the circumstances, conditions, and hardship of his active service. Therefore, the evidence of record is at the very least in relative equipoise as to whether the Veteran's diagnosed low back and coccygeal disabilities are related to active service, thus, service connection is warranted. Accordingly, after resolving all doubt in favor of the Veteran, service connection for a low back strain and residuals of a coccygeal injury is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for a neck disability. The Veteran asserts that he has a neck disability that is manifested as a result of his period of active service. During the July 2021 Board hearing, he indicated that he developed neck symptoms in the July 2005 helicopter accident during combat service in Iraq. He indicated that the service treatment records from this incident focused on the more serious low back symptoms rather than the less apparent neck symptoms. He also indicated that he had been experienced progressively worse symptoms ever since. As indicated above, the July 2005 helicopter accident has been corroborated by the United States Air Force. Moreover, while it indicates that the Veteran sustained a bruised tailbone, it is also noted that he sustained minor injuries, which on its face would suggest more than one injury. A review of the Veteran's service treatment records reveals that he was treated for neck pain in March 1985 wherein X-rays taken were negative. In December 1986, he was treated for a three month history of neck pain wherein low-mid neck pain episodes were said to limit motion in all directions. In January 1987, he was said to have re-exacerbated neck soreness with lifting weights. The Veteran's December 2009 retirement physical examination report shows that he was said to have a four to five month history of neck pain, stiffness, and tightness for which he was assessed to have cervicalgia. In the December 2009 report of medical assessment, it was indicated that the Veteran had lower cervical and high thoracic symptoms. The history of the helicopter ground mishap with compressive forces was noted. Following service, a VA examination report dated in April 2013 shows that the Veteran was diagnosed with cervical spine strain. He provided a medical history of onset of neck symptoms consistent with that as set forth above. He described ongoing progressively worse symptoms since service. The examiner could not provide an opinion as to the etiology of the condition without resorting to speculation. The examiner added that length of time since service, coupled with his employment in construction made the possibility of intercurrent injury unknown. VA outpatient treatment records dated from June 2013 to August 2016 show that the Veteran was said to have a history of chronic neck pain related to a helicopter crash in 2005. Based on the evidence of record, the Veteran has a current diagnosis of cervicalgia. As such, the evidence of record has established the existence of a current disability. Thus, the question becomes whether the current disability is related to active service. In this regard the Board has considered the April 2013 opinion of the VA examiner but finds it to be of limited probative value as an opinion could not be providing without resorting to speculation. The examiner, in part, based the conclusion on the possibility that there may have been a post-service intercurrent injury. However, there is no evidence of record demonstrating any such hypothetical intercurrent injury. The other evidence of record, to include the testimony of the Veteran, is deemed competent and credible and entitled to probative weight, as it is internally consistent and consistent with other evidence of record, that shows he had several incidents of neck treatment, along with the injuries related to the July 2005 helicopter accident, during service, and that he has had ongoing symptoms ever since. His cervical symptoms were specifically noted at service separation, and his statements as to continuity of symptoms are also afforded some greater level of probative value as he has experience as a dental assistant and combat medic. Therefore, his claims as to the onset and continuity of his neck symptoms are consistent with the circumstances, conditions, and hardship of active service. Therefore, the evidence of record is at the very least in relative equipoise as to whether the Veteran's diagnosed cervical spine strain is related to active service, thus, service connection is warranted. Accordingly, after resolving all doubt in favor of the Veteran, service connection for a cervical spine strain is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to service connection for rosacea. The Veteran asserts that he has developed rosacea that was first manifested during his period of active service. During the July 2021 Board hearing, he indicated that he developed the symptoms in service, and that they have continued intermittently ever since. The undersigned specifically observed that the Veteran exhibited active symptoms of rosacea on his face during the Board hearing. A review of the Veteran's service treatment records reveals that his February 1983 enlistment report of medical examination shows that clinical evaluation of the face and skin was normal. In the associated February 1983 report of medical history, the Veteran indicated that he had never experienced skin diseases. A September 1996 shows that the Veteran was treated for facial dermatitis for which an impression, in pertinent part, of rosacea was given. In July 1997, he was again treated for symptoms that were assessed to be possible rosacea. A two year history of symptoms was noted. In September 2009, he was treated for a finely erythematous rosacea. It was noted that symptoms had not improved with a history of steroid and antibiotic use, and that symptoms would be worse during the winter. A referral to a private dermatologist for rosacea is shown in October 2009. In December 2009, a history of rosacea is indicated. Following service, VA outpatient treatment records do not show treatment for rosacea, nor was a VA examination specifically conducted to address the nature and etiology of the condition that was demonstrated during active service. Nonetheless, the Veteran testified as to the existence of the current disability, and the undersigned specifically observed such symptoms during the July 2021 Board hearing. The evidence of record shows that the Veteran has exhibited current rosacea, thus, the existence of a current disability has been established. The evidence of record also shows that a history of rosacea was not indicated at service entrance, and the service treatment records in July 1997 show a two year history of symptoms which corroborates in-service onset. The testimony of the Veteran as to onset and continuity of symptoms is deemed to be competent and credible and entitled to probative weight as it is internally consistent and consistent with other evidence of record. Moreover, his statements as to onset and continuity of symptoms are also afforded some greater level of probative value give his experience as a dental assistant and combat medic. Therefore, the evidence of record is at the very least in relative equipoise as to whether the Veteran's has current rosacea that was first manifested during his period of active service. Accordingly, after resolving all doubt in favor, service connection for rosacea is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a left knee disability. The Veteran asserts that he has a current left knee disability that is manifested as a result of his period of active service. During the July 2021 Board hearing, it was suggested that he developed symptoms in the July 2005 helicopter accident during combat service in Iraq. He added that he continued to experience left knee symptoms. The Veteran's service treatment records reveal that the Veteran's February 1983 report of medical examination showed left knee pain was demonstrated at service entrance. It was noted that the knee had been symptomatic off and on for the preceding year. Physical examination was said to be normal, and he was deemed acceptable for service. Thereafter, in August 1984, he was treated for left knee pain after playing football wherein the assessment was soft tissue injury. In May 1990, he was treated for post-traumatic synovitis following a left knee injury while water skiing. In June and July 1992, he was treated for a possible left lateral meniscus injury. It was noted that he first injured his left knee 11 years earlier when he struck the kneecap with a chain saw, and then he re-injured the left knee 2 years earlier while water skiing. In August 1994, he was treated for a sprained knee after jumping off a deck. An October 1995 report of medical examination shows a history of a mild contusion of the left knee in September 1994. The December 2009 report of medical assessment shows that it was indicated that the Veteran had bilateral knee pain that increased with kneeling. The history of the water skiing injury to the left knee was noted. Following service, the April 2013 VA examination report shows that the Veteran was diagnosed with bilateral knee strain. The examiner could not provide an opinion as to whether the left knee had onset or had been aggravated by service without resorting to speculation. A Veteran is presumed to have been sound upon entry into active service, except as to defects, infirmities, or disorders noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). The Veteran is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. See VAOPGCPREC 3-2003. As indicated above, the examination at service entrance in February 1983 demonstrated left knee symptoms. A pre-service history of a kneecap injury is also subsequently indicated in the service treatment records. Accordingly, the Veteran is not entitled to the presumption of soundness. Under 38 U.S.C. § 1153, a preexisting injury or disease will be considered to have been aggravated by active service where there is an increase in disability during such service unless there is a specific finding that the increase in disability is due to the natural progress of the disease. Under 38 C.F.R. § 3.306(b), clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability. While not thought to be disabling, the fact remains that the Veteran entered service with known symptoms affecting the left knee. However, the April 2013 VA examiner did not apply the correct standard in addressing the left knee symptoms noted at service entrance. In this regard, in stating that it was less likely than not that the Veteran's left knee disability was aggravated by service, an opinion was not provided as to whether the pre-existing disability, as likely as not, underwent an increase in disability during service; and, if so, whether the increase in severity is clearly and unmistakably due to the natural progression. As such, the issue must be remanded for an additional medical opinion. See Colvin v. Derwinski, 1 Vet. App. 171 (1991); Hatlestad v. Derwinski, 3 Vet. App. 213 (1992); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 2. Entitlement to service connection for a left heel disability, to include left heel pain. The Veteran asserts that he has a current left heel disability that is manifested as a result of his period of active service. During the July 2021 Board hearing, it was suggested that he developed symptoms in the July 2005 helicopter accident during combat service in Iraq. He added that he continued to experience symptoms ever since. The examiner noted that he would experience tendinosis of the ligaments, and that he had been treated by a physical therapist in 2019 and 2020. The Veteran's service treatment records reveal that in October 1990, he was treated for a one week history of bilateral heel pain wherein an assessment of probably heel spurs was given. Following service, an April 2013 VA foot examination report shows that the Veteran reported onset of heel pain in service that had become progressively worse ever since. Functional impairment of the disability impacting the Veteran's ability to work was described as prolonged standing and walking would cause bilateral heel pain. The examiner concluded that there was no objective evidence of a current left heel disability. In light of the in-service findings of probable heel spurs, and the Veteran's competent and credible testimony as to treatment for current left heel symptoms in 2019 and 2020, the Board finds that the Veteran should be afforded a VA examination so as to determine the nature and etiology of the asserted current left heel disability. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); McLain v. Nicholson, 21 Vet. App. 319 (2007). Additionally, efforts should be undertaken to obtain any private medical treatment and physical therapy records of the Veteran for treatment of his asserted left heel disability. VA has a duty to obtain records of identified private medical treatment. Massey v. Brown, 7 Vet. App. 204 (1994); see also 38 C.F.R. § 3.159(e)(2). 3. Entitlement to service connection for a right ankle disability. The Veteran asserts that he has a current right ankle disability that is manifested as a result of his period of active service. During the July 2021 Board hearing, it was suggested that he developed symptoms in the July 2005 helicopter accident during combat service in Iraq. He added that he continued to experience symptoms ever since. The Veteran's service treatment records reveal that in August 1984, he was treated for right ankle pain after playing football. There was slight tenderness over the right lateral malleolus. X-ray showed no fracture. The diagnosis was soft tissue injury. The December 2009 report of medical assessment shows that it was indicated that the Veteran had bilateral ankle pain, right greater than left, medially worse with sitting or kneeling. Following service, a VA ankle conditions examination was conducted in April 2013, however, the report only addressed the left ankle and not the asserted right ankle. VA outpatient treatment records dated from July 2013 to August 2016 show intermittent treatment for symptoms associated with bilateral ankle pain and arthralgia of the ankle. In July 2013, X-rays of the right ankle revealed old fracture of the tip of the medial malleolus with nonunion and mild degenerative joint disease. In light of the in-service findings of right ankle symptoms, the post service outpatient treatment for right ankle symptoms, and the Veteran's competent and credible testimony as to onset and continuity of symptoms, the Board finds that the Veteran should be afforded a VA examination so as to determine the nature and etiology of the asserted current right ankle disability. See McLendon, 20 Vet. App. at 81. 4. Entitlement to service connection for a sinus disability. The Veteran asserts that he has a current sinus disability that is manifested as a result of his period of active service. During the July 2021 Board hearing, it was suggested that he developed symptoms during his deployments in the Southwest Asia Theater of Operations wherein he was exposed to environmental hazards to include burn pits. He added that he continued to experience symptoms ever since. It is noted that service connection for asthma, rhinitis, and sinusitis, to include rhinosinusitis, shall be service-connected even though there is no evidence of such disease during the period of service if it becomes manifest to any degree (including noncompensable) within 10 years from the date of separation from military service that includes a qualifying period of service in Southwest Asia during the Persian Gulf War, or Afghanistan, Syria, Djibouti, or Uzbekistan on or after September 19, 2001, during the Persian Gulf War. In this regard, a Veteran who has such a qualifying period of service shall be presumed to have been exposed to fine, particulate matter during such service. 86 Fed. Reg. 42, 724 (August 5, 2021), to be codified at 38 C.F.R. § 3.320. However, asthma, rhinitis, and sinusitis, to include rhinosinusitis, shall not be presumed service-connected if there is affirmative evidence that, as relevant, the disease was not incurred during or aggravated by a qualifying period of service. 86 Fed. Reg. 42, 724 (August 5, 2021), to be codified at 38 C.F.R. § 3.320. The Veteran's service treatment records reveal that in December 1991 and July 1997, he was treated for symptoms associated with sinusitis. He was also treated for an upper respiratory infection in April 2004 and February 2005, and was treated for bronchitis in February 2005. In light of the in-service findings of sinusitis, upper respiratory infection, and bronchitis, the in-service exposure to environmental toxins; and the Veteran's competent and credible testimony as to onset and continuity of symptoms, the Board finds that the Veteran should be afforded a VA examination so as to determine the nature and etiology of the asserted current sinus disability. See McLendon, 20 Vet. App. at 81; McLain, 21 Vet. App. at 319. 5. Entitlement to service connection for residuals of dental trauma. The Veteran asserts that he sustained dental trauma during his period of active service. During the July 2021 Board hearing, it was suggested that he developed microfractures of his teeth during the July 2005 helicopter accident during combat service in Iraq. He added that the microfractures could manifest in symptoms dental fractures in the future. The Veteran's service dental treatment records dated in April 2006 show that he was fitted for two crowns, though, a reason for the treatment was not indicated. The December 2009 report of medical assessment shows that in addressing the Veteran's low back symptoms, it was indicated that he had also sustained a fracture of two teeth. Under current VA regulations, compensation is only available for certain types of dental and oral conditions listed under 38 C.F.R. § 4.150, including conditions of the mandible, maxilla, ramus, condyloid process, coronoid process, hard palate, and loss of teeth due to loss of substance of the body of the maxilla or mandible. See 38 C.F.R. § 4.150, Diagnostic Codes 9900-9916. Otherwise, a Veteran may be entitled to service connection for dental conditions including treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease, for the sole purposes of receiving VA outpatient dental services and treatment, if certain criteria are met. 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 17.161. In light of the in-service findings that the Veteran was fitted for two dental crowns, the separation report of medical examination suggesting that the Veteran fractured two teeth, and the Veteran's competent and credible testimony, the Board finds that the Veteran should be afforded a VA examination so as to determine the nature and etiology of the asserted dental disability, to include whether the Veteran meets the criteria for service connection for dental and oral conditions listed under 38 C.F.R. § 4.150, or for service connection for the sole purposes of receiving VA outpatient dental services and treatment under 38 C.F.R. §§ 3.381, 1761. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); McLain v. Nicholson, 21 Vet. App. 319 (2007). 6. Entitlement to an initial disability rating greater than 20 percent for service-connected gout. 7. Entitlement to an initial compensable disability rating for service-connected kidney stones. The Veteran asserts that his service-connected gout and kidney stones disabilities are more disabling than reflected by the currently assigned, respective, 20 percent and noncompensable disability ratings. The Veteran was most recently evaluated in April 2013 VA examinations that were conducted for the purposes of establishing entitlement to service connection. During the July 2021 Board hearing, the Veteran indicated that his symptoms had increased in severity in since the most recent VA examinations that were conducted almost nine years ago. In light of the Veteran's testimony that the examination reports do not accurately reflect the extent of his symptoms, and as it has been several years since the most recent VA examinations, the Board finds that updated examinations are warranted. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also Allday v. Brown, 7 Vet. App. 517, 526 (1995). As such, on remand, the Veteran should be afforded new VA examinations to determine the current nature and severity of his service-connected gout and kidney stones. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for the 2019 and 2020 private treatment of his asserted left heel disability referenced during the July 2021 Board hearing. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. Efforts to obtain the requested documents must be annotated in the record and the Veteran notified. 2. Schedule the Veteran for a VA examination of his claimed left knee disability. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to provide a response to the following: (a) Please opine whether it is as likely as not that the Veteran's pre-existing left knee disability increased in severity during service, and if so, whether the increase in severity during service was clearly and unmistakably (obvious, manifest, and undebatable) due to the natural progression. In providing a response, the examiner must consider and address the in-service treatment for left knee symptoms, to include the August 1984, May 1990, June and July 1992, August 1994, September 1994 treatment for left knee symptoms, July 2005 helicopter accident, and any incident involving combat service. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 3. Schedule the Veteran for a VA examination for his asserted left heel disability, to include left heel pain. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to opine as to whether it is at least as likely as not that the Veteran has a left heel diagnosis, and if so, whether it at least as likely as not had its onset in service, had its onset in the year immediately following any period of service, or is otherwise the result of a disease or injury in service? The absence of evidence of treatment for a particular left heel disorder in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 4. Schedule the Veteran for a VA examination for his asserted right ankle disability. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to opine as to whether it is at least as likely as not that the Veteran has a right ankle diagnosis, and if so, whether it at least as likely as not had its onset in service, was manifested by arthritis in the year immediately following any period of service, or is otherwise the result of a disease or injury in service? The absence of evidence of treatment for a particular right ankle disorder in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 5. Schedule the Veteran for a VA examination for his asserted sinus disability. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner is asked to opine as to whether it is at least as likely as not that the Veteran has a diagnosis of asthma, rhinitis, and/or sinusitis, to include rhinosinusitis, and if so, whether it at least as likely as not had its onset in service, was manifested within 10 years following separation from active service, or is otherwise the result of a disease or injury in service? The absence of evidence of treatment for a particular sinus disorder in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 6. Schedule the Veteran for a VA dental examination for his asserted residuals of dental trauma. The examiner must review the claims file. The examiner is asked to opine as to whether it is at least as likely as not that the Veteran has (a) a dental and oral conditions listed under 38 C.F.R. § 4.150, including conditions of the mandible, maxilla, ramus, condyloid process, coronoid process, hard palate, and loss of teeth due to loss of substance of the body of the maxilla or mandible for which service connection is available under 38 C.F.R. § 4.150; or (b) a dental condition including treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease, for which service connection is available for the sole purposes of receiving VA outpatient dental services and treatment under 38 C.F.R. §§ 3.381, 17.161, as a result of his period of active service, to specifically include the July 2005 helicopter accident during combat service in Iraq. In rendering an opinion, the examiner must comment on the April 2006 service dental treatment records showing that the Veteran had been fitted for two crowns, and the December 2009 report of medical assessment showing that he had sustained a fracture of two teeth. The absence of evidence of treatment for a particular disorder in the Veteran's service treatment records cannot, standing alone, serve as the basis for a negative opinion. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered. The examiner must provide a rationale for each opinion given. 7. Schedule the Veteran for an examination to determine the current nature and severity of his service-connected gout. 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. 8. Schedule the Veteran for an examination to determine the current severity of his service-connected kidney stones. 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. In providing all of the requested opinions, the clinician(s) should consider the Veteran's reported injuries and symptoms in service and thereafter, including the nature of his reported injuries and the onset, progression and severity of his reported symptoms. If there is any medical reason to accept or reject the proposition that any of the Veteran's reported injuries and symptoms in service and thereafter represented the onset of his current disabilities, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disabilities are known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Orfanoudis, 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.