Citation Nr: 0003449 Decision Date: 02/10/00 Archive Date: 02/15/00 DOCKET NO. 97-26 450 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to service connection for the residuals of a left knee injury. 2. Entitlement to service connection for the residuals of a left ear injury to include hearing loss and tinnitus. 3. Entitlement to service connection for a genitourinary disorder to include an enlarged prostate. 4. Entitlement to service connection for a right hip disorder. WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD M. A. Herman, Associate Counsel INTRODUCTION The veteran had active military service from September 1974 to September 1984. He also served with the Army National Guard from April 1989 to March 1995. This appeal arises from an October 1996 rating decision of the Manchester, New Hampshire, regional office (RO) which denied service connection for the residuals of a left knee injury, the residuals of a left ear injury to include hearing loss and tinnitus, a genitourinary disorder to include an enlarged prostate, and a right hip disorder. FINDINGS OF FACT 1. The veteran has been variously diagnosed as having chronic left knee strain, left ear otitis media, left ear hearing loss, and tinnitus. 2. There is no competent medical evidence linking the veteran's current left knee or left ear disorder with any incident, accident, or disease that occurred during his active military service. 3. The veteran's claim for service connection for the residuals of a left knee injury is not plausible. 4. The veteran's claim for service connection for the residuals of a left ear injury to include hearing loss and tinnitus is not plausible. 5. Service department records show that the veteran was treated for complaints of frequent urination, an enlarged prostate, and right hip pain while he was a member of the Army National Guard. 6. There is no competent medical evidence linking the veteran's current right hip strain and/or enlarged prostate with any period of active duty for training (ACDUTRA) or inactive duty for training (INACDUTRA). 7. The veteran's claim for service connection for a genitourinary disorder to include an enlarged prostate is not plausible. 8. The veteran's claim for service connection for a right hip disorder is not plausible. CONCLUSIONS OF LAW 1. The claim of entitlement to service connection for the residuals of a left knee injury is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 2. The claim of entitlement to service connection for the residuals of a left ear injury to include hearing loss and tinnitus is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 3. The claim of entitlement to service connection for a genitourinary disorder to include an enlarged prostate is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). 4. The claim of entitlement to service connection for a right hip disorder is not well grounded. 38 U.S.C.A. § 5107(a) (West 1991). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Factual Background Service medical records for the veteran's period of active military service are unavailable. Multiple searches for those records through the National Personnel Records Center (NPRC) have been negative. The veteran's April 1989 enlistment examination indicated that his ears, eardrums, genitourinary system, lower extremities, and musculoskeletal system were normal. On audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 0 5 15 0 LEFT 10 0 10 20 15 In February 1992, the veteran slipped and fell on a patch of ice while walking from his car to the armory. He complained of pain in his back and groin area. A statement of medical examination and duty status indicated that the veteran was seen by medics and taken to a civilian hospital for further evaluation. The veteran was noted to be on inactive duty for training (INACDUTRA) when the accident occurred. The veteran was seen one week later due to complaints of abdominal pain that radiated into his back and down his legs. He said he had pain in his right groin, and that said pain extended down his medial leg to his ankle. He stated he had some weakness in his left knee. There was midline tenderness at T8 and L1. The right sciatic notch was also tender. There was no paravertebral spasm. Both knees were stable. The veteran experienced slight discomfort along the right pubic area. Neurological testing was normal. The impression was low back strain without neurological deficit. The veteran was referred for physical therapy. He was also excused from weekend drills and given a physical profile to avoid lifting and prolonged standing. Treatment notes from the Massena Memorial Hospital show that the veteran received physical therapy on a routine basis from March to April 1992. At his initial examination, he complained of intermittent back pain especially in the right lumbar region and right groin area. He said he experienced transient right side numbness and weakness in both his upper and lower extremities. He endorsed muscle spasm. Following strength and movement testing, the impression was back pain and possible pulled groin muscle. Subsequent treatment notes reflect a gradual improvement of the veteran's condition. The veteran was evaluated by the family practice clinic at Ft. Drum in April 1992. Although he had been receiving ongoing physical therapy for over 45 days, he said he continued to experience low back and groin pain. The examiner indicated that the veteran should be excused from attending weekend drills. He also indicated that a return to his civilian job was not advisable. At a May 1992 follow up examination, the veteran continued to complain of right groin pain. He reported that he had stopped going for physical therapy. There was tenderness along the adductors of the left thigh. There was also unevenness along the iliac crests with mild sacroiliac dysfunction. The impression was groin pull/somatic dysfunction. The examiner recommended that the veteran undergo additional physical therapy. The veteran was seen again in July 1992, after receiving approximately 30 days of physical therapy. He reported that he was feeling better. He had increased hip flexion. There was tenderness along the right sacroiliac. Deep tendon reflexes were intact. The impression was low back strain and right adductor strain. In August 1992, the veteran was evaluated by the orthopedic clinic. He complained of low back pain that radiated down his right leg to his foot. He indicated his right groin was especially tender. He denied experiencing paresthesia with sleep. He also denied having a gastrointestinal or genitourinary problems. He said he had not worked since the February 1992 injury. An examination of the right hip revealed a tender groin. No masses could be felt. Range of motion was from zero to 95 degrees with pain. X-rays of the right hip and pelvis were taken. The right hip showed no fracture. With the exception a bone island in the neck of the left femur, the pelvis was negative. The impression was lumbar strain, atypical right leg symptoms, and right groin pain. The veteran was seen by B. Bakirtzian, M.D., in October 1992. He stated that he continued to experience right groin pain despite the fact that he had received several months of physical therapy. He exhibited a flattened lordosis. He had no shift of the shoulders on the pelvis. There was no pelvic obliquity. Gross manual muscle testing in the lower extremities was within normal limits. The right hip demonstrated a decreased range of motion. There was right deep buttock tenderness as well as mild tenderness over the trochanteric bursas bilaterally. There was also acute tenderness at the insertion of the adductor group into the pelvis/groin. The assessment was adductor tendonitis, low back strain, and possible trochanteric bursitis. A subsequent October 1992 report from Dr. Bakirtzian indicated that the veteran was experiencing difficulty defecating and urinating in addition to his continued groin pain. On examination, he had tenderness in both adductor muscles of his hips. He complained of pain with straight leg raising of both legs. The examiner noted that a recent bone scan of the low back and hips had been normal. The impression was adductor tendonitis and "some urological problem." A follow up treatment note dated in November 1992 indicated that a MRI of the pelvis had been negative. In November 1992, the veteran was seen by M.L. Buscemi, M.D., due to complaints of dysuria, urinary frequency, and nocturia. He reported having no urinary problems prior to February 1992 when he slipped on ice and injured his groin. A urinalysis showed 2-5 RBC/HPF without evidence of infection. The urine for dipstick was plus one for blood. Finding that he needed to undergo a work-up for hematuria, Dr. Buscemi recommended that the veteran be afforded an intravenous pyelogram (IVP), urine cystology, and cystoscopy. The veteran was referred for a Medical Evaluation Board (MEB) in November 1992 due to his inability to lift, carry, or do any functions that required movement of his back. He denied any injury during his active military service. His history of injuring his back and groin in February 1992 and subsequent treatment for the same was discussed. The results of the aforementioned bone scan, x-rays, and MRI were also referenced. The veteran's head, ears, eyes, nose, and throat were within normal limits. A hearing exam was within normal limits. His genitourinary system was normal. A musculoskeletal examination revealed tenderness in the lumbar region with marked paraspinous spasm bilaterally. Straight leg raises were limited to 45 degrees on the left due to pain in the left groin and limited to 15 degrees on the right due to pain in the right groin. Otherwise, the extremities were within normal limits. The diagnoses were chronic low back pain and groin discomfort. Another MEB was conducted in July 1994. The veteran complained of chronic low back and groin pain. He said the pain in his right groin would often extend from his penis to his knee. He stated that he also experienced periodic pain in the left groin. He further indicated that an injury to his left ear and an enlarged prostate should be included among the injuries related to his military service. In this regard, the veteran reported that he suffered from mild high frequency hearing loss of the right ear, sensorineural hearing loss of the left ear with scarred left tympanic membrane, an enlarged prostate, and increased urinary frequency. He said his left eardrum was damaged when he was traveling in an 880 truck, and that he had been suffering ear infections since that time. He maintained his prostate/genitourinary problem was related to his 1992 groin injury. The veteran further indicated that he had arthritis in his right and left hips. On physical examination, the veteran's left tympanic membrane was thickened. However, there was no evidence of perforation, cholesteatoma, or active disease. The right tympanic membrane was normal. On audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 5 30 30 LEFT 35 20 30 40 40 The veteran's abdomen was soft and without guarding or rigidity. There was no suprapubic tenderness, palpable pelvic masses, or herniations. However, he was very tender in both groin areas and down into the medial thighs. His penis appeared normal. Both testes were descended. There were no varicoceles, cystoceles, or scrotal edema. The veteran had a small bilaterally symmetric prostate with no hypertrophy or induration. No disproportionate urgency was demonstrated at exam. The lower extremities were symmetric with rather prominent pelvic flexion on standing. There was no buttock atrophy. While there was no wasting of the thighs, the veteran was exquisitely tender from the area of the symphysis pubis on down both medial thighs to the inside of his knees. Thigh adduction increased the symptoms. He was essentially unable to abduct and used a compensatory pelvic shift instead. A urinalysis was positive for a small amount of blood. A March 1994 IVP for micro hematuria was noted to have been normal. The diagnoses were mechanical low back pain and chronic groin pain secondary to adductor tendonitis. The examiner recommended that the veteran's physical profile be reduced, and that he be returned to duty. In August 1994, the MEB determined that the veteran's mechanical low back pain and chronic groin pain secondary to adductor tendonitis were the result of injuries that occurred when he was entitled to base pay. His case was referred to the Physical Evaluation Board (PEB). He was discharged due to disability in March 1995. In August 1995, the veteran filed a claim for service connection for damage to his left eardrum, an enlarged prostate, the residuals of an injury to his left knee, and the residuals of an injury to the groin and back with arthritis of the right hip. He submitted a report of a March 1994 IVP showing that he had an enlarged prostate. No other genitourinary conditions were noted. The veteran was afforded a series of VA medical examinations in March 1996. At his general medical examination, he said he had been suffering from an enlarged prostate since 1994. He complained of frequent nighttime urination. He stated he had occasional "dribbling" and some sharp pain in the penis. He reported that his erectile function was normal. A rectal examination was performed. In this regard, the veteran's prostate was moderately enlarged. The prostate was soft, boggy, and smooth. There was a sulcus between the lobes. The attachment of the tendons to the pelvic rami showed tenderness. The diagnosis, in pertinent part, was prostatic enlargement. At his orthopedic examination, the veteran reported injuring his low back in 1992. He said he received physical therapy for several months, but that he failed to experience any significant improvement in his condition. He complained of chronic low back pain that extended into his lower extremities. He gave a history of right hip pain since 1993. He also endorsed periodic left knee pain with some crepitation. The range of motion of the veteran's right hip was 20 degrees of internal rotation, 30 degrees of external rotation, 95 degrees of flexion, zero (0) degrees of extension, 40 degrees of abduction, and 30 degrees of adduction. There was mild pain on extremes of motion. There were no areas of swelling, discoloration, or tenderness. The left knee had full extension and 135 degrees of flexion. There was crepitation on both flexion and extension. No joint effusion was noted. An x-ray of the left knee was within normal limits. An x-ray of the right hip revealed no evidence of a recent bone injury. However, there was a mild superior acetabular sclerosis and some slight deformity of the right femoral head. The joint space was not narrowed. The diagnoses, in pertinent part, were chronic right hip strain and chronic left knee strain. The veteran was also afforded a VA ear examination in March 1996. He said he damaged (ruptured) his left eardrum in 1977. Since that time, he stated he had suffered frequent ear infections and hearing loss in that ear. He reported that the infections occurred about once a week. He also indicated that he had been experiencing periodic bilateral tinnitus since the 1977 ear injury. The auricles were normal. The left external canal showed some chronic inflammatory changes and the left tympanic membrane showed some mild scarring. The tympanums and mastoids were normal. There was no active ear disease present. On the authorized audiological evaluation, pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 5 5 25 15 LEFT 25 20 20 40 35 Speech audiometry revealed speech recognition ability of 100 percent in the right ear and of 96 percent in the left ear. The diagnoses were hearing loss, left Eustachian tube dysfunction, and left chronic external otitis. By a rating action dated in October 1996, service connection for low back strain and groin pain secondary to abductor tendonitis was granted. The claims of service connection for right hip arthritis, a genitourinary condition, and the residuals of injuries to the left knee and left ear were denied. The veteran was afforded a personal hearing before the RO in March 1997. He asserted that his current genitourinary problem to include an enlarged prostate was a direct result of the 1992 fall that had also injured his low back and groin. He said he immediately noticed an increase in his need to urinate following the 1992 accident. He stated that subsequent testing eventually showed that he had an enlarged prostate. The veteran opined that he somehow injured his penis in 1992, that the injury led to his initial genitourinary problems, and finally to his prostate condition. With regard to his left ear, the veteran maintained that he injured said ear in the late 1970s while riding on the back of an 880 truck. He said the truck was driving fast, and that the pounding wind damaged his eardrum. After noticing swelling of the ear, he stated that he reported for treatment the next day. He said he was told that his eardrum had been damaged. The veteran asserted he had been experiencing problems with his left ear since that time. These problems included frequent ear infections, a gradual loss of hearing, and tinnitus. He testified that hearing loss was demonstrated at his 1989 enlistment examination, but that the examiner did not think it was disabling enough to disqualify him from serving with the National Guard. He denied seeking any professional treatment for any of these conditions. The veteran further reported that he injured his left knee in 1981 when he slipped between a train and the platform. He said he received stitches for a laceration and was on crutches for approximately two weeks. He stated he had a scar on his knee. He contended that the problems with his left knee had worsened over the years. The veteran indicated that he had developed crepitation in that knee. Noting that the service medical records from the veteran's period of active military service were missing, the veteran's former representative indicated that VA had a heightened duty to assist him in the development of his claim. In this regard, the representative observed that the RO had yet to inform the veteran that he could submit "alternate" evidence to support his allegations of injuring his left knee and left ear in service. The veteran submitted a statement from his mother in further support of his claim. While visiting home on leave, she recalled that the veteran developed significant ear pain and a swollen face. She said he was taken to an emergency clinic for treatment. In July 1997, the Hearing Officer denied the claims of service connection for the residuals of a left knee injury, a left ear condition with hearing loss and tinnitus, and a genitourinary condition to include an enlarged prostate. He found that the veteran had failed to submit any medical evidence that related any current left ear or left knee problem with his active military service, active duty for training (ACDUTRA), or INACDUTRA. Observing that the veteran was treated for hematuria sometime after his 1992 injury, the Hearing Officer stated that said condition was not a ratable disability but rather a symptom of an underlying pathology or injury. In this regard, he said the hematuria eventually resolved, and that it had not been linked to any chronic disability. He further concluded that there were no findings that the veteran's diagnosed enlarged prostate manifested during his active service, or that the enlarged prostate was a result of a traumatic injury that occurred while serving with the Army National Guard. In a statement received in October 1997, S. Cheng, M.D., reported that the veteran had been evaluated for complaints of hip and knee pain. Dr. Cheng stated the veteran had degenerative changes of the right hip and knee joints. He stated that a consultation with an orthopedic surgeon had been scheduled. Medical records from the Manchester VA Medical Center (VAMC) dated from March 1997 to October 1997 were associated with the claims folder. Those records show that the veteran received evaluations and treatment for, but not limited to, irritable bowel syndrome, low back pain, multiple joint pain, left otitis, and groin pain. Of note, the veteran was seen in June 1997 for complaints of a productive cough, swelling of the left lower lip, and left ear pain. He was diagnosed as having left otitis media with sinusitis and a herpetic cold sore. The veteran was evaluated for complaints of right knee pain in September and October 1997. In October 1997, he reported his right knee would lock up while walking. He said he continued to experience right groin pain with hip flexion and weight bearing. He indicated that he slept with a pillow under his right knee to alleviate the pain. On examination, there was no evidence of anterior drawer or lateral instability. There was crepitus of the knee. Groin pain was elicited with internal/external rotation and straight leg raising. The impression was osteoarthritis of the right hip and knee. Later that month, the veteran was seen for complaints of left knee pain as well as right knee pain. He gave a history of injuring his left knee and right groin in service. He said his knee problems had grown progressively worse over time. He had a full range of motion of the knees and hips. There was crepitation. X-rays were noted to have shown osteoarthritis of the right hip and knee. The impression was osteoarthritis of the right hip and knee. The veteran was afforded a VA orthopedic examination in November 1997 for the purpose of evaluating his service- connected low back disability. There were no pertinent findings regarding his hip and/or left knee. In July 1999, the veteran was afforded a VA general medical examination for the express purpose of evaluating his right hip and groin condition. His history of injuring his right hip and groin in 1992 and treatment for the same was discussed. Flexion of the hips was to 125 degrees bilaterally. However, pain in the right hip and groin was demonstrated with flexion of the right hip. Range of motion of the right hip was diminished slightly with extension and abduction, when compared to the left hip. Deep tendon reflexes were equal and active bilaterally. There was no weakness on flexion and extension in either thigh, knee, ankle, or toe. With the pinpoint, there was no lack of discrimination in the right groin. An x-ray of the right hip was negative. The diagnosis was abductor tendonitis of the right groin with residual symptoms. The examiner found that acetabular sclerosis was no longer evident, and that repeat x-rays of the right hip showed no evidence of any degenerative changes. There was also no evidence of trochanteric bursitis. The examiner indicated that the veteran's claims folder had been reviewed. In July 1999, the claims of service connection for the residuals of a left knee injury, the residuals of a left ear injury, a genitourinary disorder, and arthritis of the right hip were denied. The RO held there was no evidence demonstrating that the veteran has arthritis of the right hip. A supplemental statement of the case was mailed to the veteran in August 1999. II. Analysis 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 by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303(a) (1999). Where a veteran served 90 days or more during a period of war, and sensorineural hearing loss or arthritis becomes manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991); 38 C.F.R. §§ 3.307, 3.309 (1999). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (1999). Active military service is defined, in part, as active duty and any period of ACDUTRA during which the individual was disabled or died from a disease or injury incurred or aggravated in line of duty, or from injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. § 101(24) (West 1991). Neither the presumption of soundness on entrance into service, nor the presumption of service incurrence for arthritis manifest to a compensable degree within the year after service, applies when service was ACDUTRA or INACDUTRA. Paulson v. Brown, 7 Vet. App. 466 (1995). A person who submits a claim for benefits under a law administered by the Secretary shall have the burden of submitting evidence sufficient to justify a belief by a fair and impartial individual that the claim is well grounded. The Secretary shall assist such a claimant in developing the facts pertinent to the claim. 38 U.S.C.A. § 5107(a). Thus, the threshold question to be addressed in this case is whether the veteran has presented evidence of a well-grounded claim. If the veteran has not presented a well-grounded claim, the appeal must fail because the Board has no jurisdiction to adjudicate the claim. Boeck v. Brown, 6 Vet. App. 14, 17 (1993). In Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997), cert. denied sub nom. Epps v. West, 118 S. Ct. 2348 (1998), the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that, under 38 U.S.C.A. § 5107(a), the Department of Veterans Affairs (VA) has a duty to assist only those claimants who have established well grounded (i.e., plausible) claims. More recently, the U.S. Court of Appeals for Veterans Claims (Court) issued a decision holding that VA cannot assist a claimant in developing a claim which is not well grounded. Morton v. West, 12 Vet. App. 477 (July 14, 1999), req. for en banc consideration by a judge denied, No. 96-1517 (U.S. Vet. App. July 28, 1999) (per curiam). Because a well-grounded claim is neither defined by the statute nor the legislative history, it must be given a commonsense construction. A well-grounded claim is a plausible claim, one which is meritorious on its own or capable of substantiation. Such a claim need not be conclusive but only possible to satisfy the initial burden of 38 U.S.C.A. § 5107(a). Murphy v. Derwinski, 1 Vet. App. 78 (1990). However, to be well grounded, a claim must be accompanied by evidence that suggests more than a purely speculative basis for granting entitlement to the requested benefits. Dixon v. Derwinski, 3 Vet. App. 261, 262-263 (1992). The Court has held that evidentiary assertions accompanying a claim for VA benefits must be accepted as true for purposes of determining whether the claim is well grounded. Exceptions to this rule occur when the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Where the determinative issue involves medical causation or a medical diagnosis, competent medical evidence to the effect that the claim is plausible or possible is required. Murphy, 1 Vet. App. at 81. A claimant would not meet this burden merely by presenting lay testimony, because lay persons are not competent to offer medical opinions. Espiritu, 2 Vet. App. at 495. A claim for service connection requires three elements to be well grounded. There must be competent evidence of a current disability (a medical diagnosis); incurrence or aggravation of a disease or injury in service (lay or medical evidence); and a nexus between the in-service injury or disease and the current disability (medical evidence). The third element may be established by the use of statutory presumptions. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). In the alternative, the chronicity provisions of 38 C.F.R. § 3.303(b) are applicable where evidence, regardless of its date, shows that a veteran had a chronic condition in service, or during an applicable presumptive period, and still has such condition. Such evidence must be medical unless it relates to a condition as to which under case law of the Court, lay observation is competent. If chronicity is not applicable, a claim may still be well grounded on the basis of 38 C.F.R. §3.303(b) if the condition is noted during service or during an applicable presumptive period, and if competent evidence, either medical or lay, depending on the circumstances, relates the present condition to that symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). A. Residuals of a Left Knee Injury and the Residuals of a Left Ear Injury to include Hearing Loss and Tinnitus The veteran claims to have sustained injuries to his left knee and left ear during his active military service. Evidentiary assertions by the veteran must be accepted as true for the purposes of determining whether a claim is well grounded, except where the evidentiary assertion is inherently incredible or when the fact asserted is beyond the competence of the veteran. King v. Brown, 5 Vet. App. 19, 21 (1993). However, in the present case, there is no medical evidence to establish a causal link between the veteran's current left knee or left ear problems and active military service. The veteran has not offered any medical opinion that attributes his diagnosed chronic left knee strain to his alleged inservice left knee injury. Similarly, there is no credible medical evidence demonstrating a relationship between any incident, accident, or disease occurring during his military service and his currently diagnosed left ear otitis media, left ear hearing loss, and tinnitus. The veteran's opinion that there is an etiological relationship between the alleged injuries he sustained to his left knee and left ear in service and his current diagnosis of chronic left knee strain, left ear otitis media, left ear hearing loss, or tinnitus does not meet this standard. Questions of medical diagnosis or causation require the expertise of a medical professional. See Espiritu. There is no evidence that the veteran has the medical background sufficient to render such an opinion. There is also no evidence showing that the veteran's alleged left knee injury and left ear injury resulted in any chronic disability. In this regard, the Board of Veterans' Appeals (Board) notes that the veteran's lower extremities, ears, and tympanic membranes were found to be normal on examination in 1989. His hearing was also noted to be within normal limits. Moreover, at his 1992 MEB, the veteran denied any history of injury during his previous period of active service. Despite the foregoing, as previously referenced, a claimant may still obtain the benefit of § 3.303(b) by providing evidence of continuity of symptomatology. Evidence of continuity is determined by symptoms not treatment. However, in determining the merits of a claim, the lack of evidence of treatment may bear on the credibility of the evidence of continuity. Equally important, since a lay person is not competent to render an opinion pertaining to the diagnosis of chronic knee strain, otitis media, hearing loss, or tinnitus, medical evidence is required to demonstrate a relationship between those disorders and any symptoms experienced post- service. See Grottveit v. Brown, 5 Vet. App. 91 (1993); Layno v. Brown, 6 Vet. App. 465 (1994). No such medical evidence has been submitted in this case. Based on the above, the Board concludes that the veteran has not submitted well-grounded claims, and his claims for service connection for the residuals of a left knee injury and the residuals of a left ear injury to include hearing loss and tinnitus must be denied. As referenced above, the veteran's service medical records for his period of active service are unavailable. In this regard, the Board notes that there is a heightened obligation to assist the claimant in the development of his case in cases where the veteran's service medical records are unavailable through no fault of the claimant. O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.303(a) (1999). Where service medical records are unavailable, the heightened duty to assist includes the obligation to search for alternate methods of proving service connection. See Moore v. Derwinski, 1 Vet. App. 401 (1991). There is no evidence that the RO informed the veteran of the opportunity to submit alternate evidence to show incurrence of his alleged left knee and left ear injuries. However, as referenced above, the veteran's claims of service connection are being denied on the basis that he failed to submit any credible medical evidence establishing an etiological relationship between any current disorder of the left knee or left ear and his alleged inservice injuries. At this time, the Board finds that no useful purpose would be served in Remanding this matter for additional development. B. Genitourinary Disorder to include an Enlarged Prostate and Right Hip Disorder Here, there is no medical evidence to establish a causal link between the veteran's current enlarged prostate or right hip disorder and military service. The veteran has not offered any medical opinion that attributes his diagnosed enlarged prostate, chronic right hip strain, or claimed osteoarthritis of the right hip to his military service. The veteran's opinion that there is an etiological relationship between any injury that occurred during a period of ACDUTRA or INACDUTRA and his current diagnosis of these conditions does not meet this standard. Questions of medical diagnosis or causation require the expertise of a medical professional. See Espiritu. Again, there is no evidence that the veteran has the medical background sufficient to render such an opinion. The Board notes that there are findings of complaints of right hip pain, hematuria, and an enlarged prostate while the veteran served with the Army National Guard. There is also evidence that the veteran slipped and fell while on INACDUTRA in February 1992, and that he sustained injuries to his low back and right groin as a result of said fall. These conditions were found to have been incurred in the line of duty and were held by the RO to be service connected. However, there is no evidence showing that the veteran's subsequent development of right hip disability, hematuria, or an enlarged prostate was related to the February 1992 fall or any other injury that occurred during a period of ACDUTRA or INACDUTRA. Accordingly, the Board finds that the veteran's claims for service connection are not well grounded because there is no competent evidence establishing that a current disability of the genitourinary system to include an enlarged prostate or a right hip disorder are causally related to disease or injury incurred during his ACDUTRA or INACDUTRA. ORDER Entitlement to service connection for the residuals of a left knee injury is denied. Entitlement to service connection for the residuals of a left ear injury to include hearing loss and tinnitus is denied. Entitlement to service connection for a genitourinary disorder to include an enlarged prostate is denied. Entitlement to service connection for a right hip disorder is denied. BARBARA B. COPELAND Member, Board of Veterans' Appeals