Citation Nr: 0003923 Decision Date: 02/15/00 Archive Date: 02/23/00 DOCKET NO. 97-20 262A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUES 1. Entitlement to service connection for bilateral hearing loss. 2. Entitlement to service connection for right elbow epicondylitis. 3. Entitlement to service connection for migraine headaches with syncope episodes. 4. Entitlement to service connection for a left knee injury. REPRESENTATION Appellant represented by: California Department of Veterans Affairs ATTORNEY FOR THE BOARD L. McCain Parson, Associate Counsel INTRODUCTION The veteran had verified service from October 1973 to November 1975. These matters come before the Board of Veteran's Appeals (Board) on appeal from an April 1997 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. The January 1997 and February 1998 VA examinations raise the issues of entitlement to service connection for tinnitus, a neck disability characterized as degenerative disc disease of the cervical spine, depression, left ankle edema, and elevated blood pressure. Where a review of all documents and any oral testimony reasonably reveals that the claimant is seeking a particular benefit, the Board is required to adjudicate the issue of the claimant's entitlement to such a benefit, or if appropriate, to return the issue to the RO for development and adjudication of the issue. See Suttman v. Brown, 5 Vet. App. 127, 132 (1993); EF v. Derwinski, 1 Vet. App. 324, 326 (1991). As these issues have not been developed for appellate review, the Board refers the issues of entitlement to service connection for tinnitus, a neck disability characterized as degenerative disc disease of the cervical spine, depression, left ankle edema, and elevated blood pressure to the RO for appropriate action. The veteran withdrew his request for a personal hearing before a member of the Board in March 1998. Effective March 1, 1999, the United States Court of Veterans Appeals changed its name to the United States Court of Appeals for Veterans Claims (hereinafter, "the Court"). FINDINGS OF FACT 1. Bilateral hearing loss was not present during service and is not related to any incident of service. 2. Right elbow pain, diagnosed as right elbow epicondylitis, was demonstrated during the veteran's active military service. 3. Migraine headaches with syncope episodes were demonstrated during active military service. 4. Patellar femoral syndrome of the left knee was demonstrated during active military service. CONCLUSIONS OF LAW 1. Bilateral hearing loss was not incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 5107(a) (West 1991); 38 C.F.R. § 3.303 (1999). 2. Resolving all reasonable doubt in favor of the veteran, right elbow pain, diagnosed as right elbow epicondylitis, was incurred during his military service. 38 U.S.C.A. §§ 1110, 5107(a); 38 C.F.R. §§ 3.102, 3.303. 3. Migraine headaches with syncope episodes had its onset in military service. 38 U.S.C.A. §§ 1110, 5107(a); 38 C.F.R. § 3.303. 4. Patellar femoral syndrome of the left knee was incurred during his military service. 38 U.S.C.A. §§ 1110, 5107(a); 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board finds that the veteran's claims are well-grounded in accordance with 38 U.S.C.A. § 5107 (West 1991), that is, his claims are plausible based upon clinical evidence of a current diagnosis of injuries related to his period of service. See Caluza v. Brown, 7 Vet. App. 489 (1995). After a review of the evidence of record, the Board concludes that the duty to assist the veteran in the development of evidence pertinent to his claim has been satisfied. See 38 U.S.C.A. § 5107. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a); see also Degmetich v. Brown, 104 F.3d 1328, 1331-32 (Fed.Cir. 1997). In addition, if a condition noted during service is not shown to be chronic, then generally a showing of continuity of symptomatology after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also be granted on the basis of a post-service initial diagnosis of a disease, where the physician relates the current condition to the period of service. In such instances, however, a grant of service connection is warranted only when "all the evidence, including that pertinent to service, establishes that the disease was incurred during service." 38 C.F.R. § 3.303(d). A. Bilateral hearing loss In essence, the veteran contends that his military occupational specialty, air frame repair specialist, resulted in his hearing loss. He was exposed to rivet guns, aircraft engine whine or blast, and aerospace ground equipment throughout his military career. For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies 500, 1000, 2000, 3000, 4000 Hertz is 40 decibels or greater; or when the auditory thresholds for at least three of the frequencies 500, 1000, 2000, 3000, or 4000 Hertz are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. See 38 C.F.R. § 3.385 (1999). If there is a current hearing loss disability for VA purposes, (i.e., satisfying the criteria of 38 C.F.R. § 3.385), then evidence must be submitted that establishes a causal connection between service and the current disability. See Hensley v. Brown, 5 Vet. App. 155, 160 (1993). Hence, even though a veteran may not have had hearing loss at the time of separation from service, he or she may still establish service connection by meeting the above the requirements. Id. Service medical records dated for the period from July 1973 to November 1975 reflect that the veteran's auditory thresholds on enlistment were 0, 0, 0, -, 0, and 0, 0, 0, -, 0 in the right and left ears respectively. An April 1974 Supplemental Medical History (for hazardous occupations) reflects that the veteran has been exposed to welding, grinding, and hazardous noise and that his occupation was air frame repair. A reference audiogram dated in May 1974 reflects auditory thresholds of 20, 25, 25, 25, 25, and 30, 30, 25, 20, 25 in the right and left ears respectively. The September 1974 audiogram reflects auditory thresholds of 35, 30, 25, 25, 45, and 25, 25, 25, 25, 35 in the right and left ears respectively. A Supplemental Medical History (for hazardous occupations) reflects that he has worked with metal grinding and hazardous noise. The September 1974 report of medical history reviewed by a medical corpsman reflects questionable hearing loss - normal on this examination. A hearing conservation data sheet dated in February 1975 reflects auditory thresholds of 10, 20, 10, 15, 10, and 30, 15, 20, 20, 30 in the right and left ears respectively. A hearing conservation data sheet dated May 28, 1975 reflects auditory thresholds of 35, 30, 35, 35, 40, and 35, 35, 35, 45, 50 in the right and left ears respectively. A June 1975 hearing conservation data worksheet reflects that the veteran has worked as a structural repairmen for 2 years and that he is on the flight line. The auditory thresholds were 50, 55, 60, 65, 80 and 40, 40, 45, 50, 60 in the right and left ears respectively. Other entries dated in June 1975 reflect a physical profile serial report which reflects a "significant hearing threshold shift", progressive bilateral hearing loss "despite" his removal from the noise hazardous environment and his use of ear plugs, and tinnitus when in a quiet environment occasionally associated with cephalalgia, as well as evaluate for malingering. The July 1975 hearing conservation data record shows hearing loss, that the veteran had been exposed to a rivet gun, and that an [audiology] consult was done. The initial ear, nose, and throat clinic consultation on September 8, 1975 indicated that the audiogram was inconsistent. The auditory thresholds were 85, 85, 90, 90, 90 and 75, 95, 100, NR, NR, in the right and left ears respectively. Speech discrimination in the right ear was 96 percent and 92 percent in the left ear. The report reflects hearing loss and "?" non-organic component. Additional comments recorded on the hearing evaluation reflect non-organic loss "?", Stenger negative, and 30 to 40 decibels difference between the puretone average and speech reception threshold. A subsequent audiogram completed for separation on September 18, 1975 reflects that the veteran's ears (i.e., auditory acuity) were evaluated as abnormal. The report of medical examination shows significant hearing loss by audiogram and that he heard conversation well. Item 71 of the report of medical examination reflects auditory thresholds of 80, 85, 95, 90, 90, and 75, 85, 85, 90, 90 in the right and left ears respectively. Item 73, notes and significant or interval history, demonstrates that the veteran was presently being processed for separation under the provisions of AFM 39-12. Item 74, summary of defects and diagnoses, reflects, inter alia, that the evaluation of the ears (Item 22) and the audiometer results (Item 71) demonstrated normal hearing and made reference to a consultation [report]. Item 75, recommendations - further specialist examinations indicated, reflects that there were no mental or physical defects that would warrant action under the provisions of AFM 35-4. Item 76, physical profile, reflects that the veteran was issued a hearing profile of "1" which demonstrated a high level of medical fitness. A subsequent consultation in October 1975 noted by the examiner who completed the September 18, 1975 separation examination reflects normal hearing. A service department record dated in November 1975 reflects that it had been determined by [the medical corps] that there were no mental or physical defects that would warrant actions under the provisions of AFM 35-4, and that the veteran was qualified for separation. The private medical records of Dr. Schlosser dated for the period of January 1990 to December 1996 make no mention of hearing loss or difficulty hearing. A detailed January 1997 VA general medical examination is silent as regards hearing loss. The veteran was accorded VA audiological examinations in January and February 1997. The audiologist noted that the second VA examination was an attempt to elicit valid compensation and pension information. The auditory thresholds were 35, 25, 30, 40, 45, and 35, 25, 20, 25, 30 in the right and left ears respectively. The puretone average in the right ear was 35 and 25 in the left ear. The Maryland CNC speech recognition score was 94 percent in the right ear and 84 percent in the left ear. The audiologist's summary reflects that the results from "today" and those of "a week ago" show a hearing loss ranging from a moderately severe to a mild hearing loss. The responses to both speech and puretone stimuli were very inconsistent within each specific test as well as in support of each other. The veteran did not appear to present any difficulty during the interview or in communicating with others at various appointments at this clinic. The audiologist opined that the veteran may possibly have a hearing impairment, but the test results are inconsistent and probably not an accurate measure of his hearing capability. The veteran was thoroughly counseled with regards to the importance of test and inter-test consistency before being re-evaluated two times. The audiologist added that the results were not recommended for adjudication. Audiograms dated in November and December 1997 are of record. The December 1997 audiogram reflects a speech discrimination score of 90 percent in the right ear and 40 percent in the left ear. The origin of these audiograms is unclear. It is not apparent whether these audiograms were conducted in accordance with VA regulations. See 38 C.F.R. § 4.85. A February 1998 VA general medical examination reflects that the veteran has impaired hearing, bilaterally. The examination also reflects that the veteran was employed as a missile launch service mechanic until June 1993 when he began receiving Social Security disability benefits for an unrelated condition. The examiner did not provide a nexus opinion. At the outset, the Board stresses that this claim was well- grounded on the basis of the audiological discrepancies in- service even though the separation examination concluded that the hearing was normal and the February 1998 VA general medical examination which diagnosed impaired hearing. However, in light of the extensive audiological evaluations in-service for inconsistent test results with an ultimate finding of normal hearing and similar testing post service, the Board must conclude that the preponderance of the evidence is against a finding that the veteran has a hearing loss disability related to his military service. In reaching this determination, the Board has considered and evaluated all evidence of record including the medical opinion contained in the February 1997 VA audiology examination together with the February 1998 general medical examination. The Board notes that while the September 1974 report of medical examination noted questionable hearing loss, the hearing was normal on that examination. Thereafter, the veteran presented with what appeared to be progressive hearing loss. Serial audiology examinations in 1975 noted that the veteran presented with progressive hearing loss despite his being reassigned from the hazardous noise environment. At that time, there was concern that the veteran was malingering. Although the audiometer results obtained for separation in September 1975 reflect impaired hearing, the ultimate conclusion following ear, nose, and throat consults was that the veteran's hearing was normal. It is curious to note that the veteran gave a detailed history on the VA joints examination accorded him in January 1997. Not one mention was made by the examiner that the veteran was hard of hearing or that he had difficulty communicating. Most important, prior to the January and February 1997 VA audiology examinations, the veteran was thoroughly counseled with regards to the importance of test and inter-test consistency before being re-evaluated two times. Following the second test, the VA audiologist opined that the veteran may possibly have a hearing impairment, but the test results were inconsistent and probably not an accurate measure of his hearing capability. Although the examiner noted that the veteran may possibly have hearing loss, he did not recommend using the results for adjudication. In that regard, there is no competent clinical evidence that demonstrates a hearing loss or a medical opinion establishing a nexus to incidents in-service (i.e., rivet guns or aircraft engine whine). Although bilateral impaired hearing was diagnosed on the February 1998 VA general medical examination, the use of those words alone are not adequate to establish that the alleged impaired hearing is related to his military service. Of note, there is no reliable audiology examination of record to support a diagnosis of hearing loss. The Board has also considered the veteran's assertions that he was exposed to hazardous noise as an air frame repair specialist while in the military and that his present hearing loss is related to that military service. The Board does not dispute that he was exposed to hazardous noise in-service. However, the evidence of record also reflects that the veteran was employed as a missile launch service mechanic as recent as June 1993. This evidence suggests that the veteran may have had other noise exposure beyond his military service. As it is in the province of trained professionals to enter conclusions which require medical opinions as to causation, see Jones v. Brown, 7 Vet. App. 134, 137 (1994), the veteran's lay assertions are not competent evidence that the currently diagnosed impaired hearing existed since service, and are of no probative value. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992); Heuer v. Brown, 7 Vet. App. 379, 384 (1995). In summary, the evidence shows that impaired hearing was not manifest on separation from service, that the veteran was employed as a missile launch service mechanic in June 1993, and that there are no reliable audiograms since service to establish that the currently diagnosed impaired hearing is related to any incident of service. Accordingly, because the preponderance of the evidence does not indicate a hearing impairment on separation from service or that any current hearing impairment is related to the incidents of his military service, his claim for service connection for bilateral hearing loss must be denied. B. Right elbow epicondylitis The veteran asserts that he fractured his right elbow in December 1973 or January 1974 when he slipped and fell on an icy walkway hitting his right elbow at Chanute Air Force Base. The service medical records for the period of July 1973 to November 1975 reflect that the upper extremities were evaluated as normal on enlistment. Service medical records created at Chanute Air Force Base dated in December 1973 and January 1974 reflect right arm and elbow pain, that he fell on his right elbow three weeks ago and then re-injured the [elbow]. The physical examination reflects tenderness over the olecranon. The x-ray reports reflect that there was no fracture, dislocation, or other significant abnormality seen. The impression was bruised olecranon. The plan was to pad the elbow. The September 1974 and September 1975 report of medical examinations reflect that the upper extremities were evaluated as normal. The private medical records from Dr. Schlosser dated for the period of January 1990 to December 1996 reflect that in May 1996 the veteran had some right lateral epicondylitis and had not really tried anything for it. On examination, there was tenderness over the lateral epicondyle on the right arm but there was no swelling, and he had normal range of motion. Inter alia, the assessment was mild right lateral epicondylitis. A forearm strap was recommended for the tennis elbow as well as over the counter anti-inflammatories. In August 1996, the veteran mentioned an ongoing problem with his right elbow. On examination, there was some very mild tenderness around the lateral epicondyle with good range of motion and no swelling. A subsequent entry in August 1996 reflects recheck - "?" possible right elbow injection. The January 1997 VA joints examination reflects that the veteran slipped on snowy ground in December 1973 striking his right elbow against the pavement. The right elbow immediately became painful and edematous. He was evaluated at the base hospital at Chanute Air Force Base following the injury. X-rays of the right elbow did not reveal evidence of fracture. He has experienced frequent right olecranon area pain since the December 1973 injury. The right elbow pain has gradually increased in frequency and severity. The right elbow pain has been constant for the past few years. The onset of cold and damp weather increased the right elbow pain. The examiner noted that the veteran's right elbow strength has been significantly impaired in recent years. The examiner noted that the specific cause of the veteran's recurring right elbow pain and impaired right arm strength was undetermined. The January 1997 x-ray of the right elbow was normal. The veteran was accorded a VA examination in February 1998. The examiner recorded the same history as reported in January 1997. The diagnostic impression reflects that the veteran sustained an injury to his right elbow in December 1973, that he had experienced frequent right olecranon area and right lateral elbow pain since the injury, and that right elbow epicondylitis is believed to be the cause of the veteran's recurring right elbow area pain. The right elbow x-ray of January 1997 was normal. From the foregoing competent evidence, it is apparent that the veteran sustained a right elbow injury in December 1973 while on active duty, that he has suffered right elbow pain at least since service as demonstrated by private and VA medical records, that he was diagnosed with a bruised and tender olecranon while on active duty in January 1974, and that he continues to have pain and tenderness over the olecranon currently diagnosed as right elbow epicondylitis by private and VA physicians in 1996, 1997, and 1998. See Caluza v. Brown, 7 Vet. App. 498 (1995); 38 C.F.R. § 3.303. Despite the interval of time since the initial injury, the veteran has presented a consistent history, without any intercurrent injury or pathology to the right arm or elbow subsequent to the prior injury and treatment. See Cartright v. Derwinski, 2 Vet. App. 24 (1991) (Section 3.303(b) requires continuity of symptomatology, not continuity of treatment). In such circumstances, a grant of service connection is warranted only when all the evidence, including that pertinent to service, establishes that the disease was incurred in-service. See Savage v. Gober, 10 Vet. App. 488 (1997); 38 C.F.R. § 3.303(d). In light of the right elbow injuries in-service, the continuity of symptoms post-service, the in-service and post-service diagnoses of right elbow pain/ olecranon tenderness/ epicondylitis, it is the Board's judgment that the evidence is in equipoise regarding the claim, which raises consideration of the benefit of the doubt doctrine. As such, the benefit of the doubt is resolved in the veteran's favor. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Therefore, service connection for right elbow pain, diagnosed as right elbow epicondylitis, is warranted. C. Service connection for migraine headaches with syncope and a left knee injury As reasoned in the earlier discussion, service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a pre-existing injury suffered or disease contracted in line of duty. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. At the outset, the Board acknowledges that the RO concluded that these conditions pre-existed the veteran's military service. In that regard, the Board notes that subsequent to enlistment, the veteran reported having headaches prior to enlistment and having sustained a left knee injury in high school. However, his reports following a normal enlistment examination are insufficient without a factual predicate in the record to support a finding that these conditions existed prior to enlistment. See 38 U.S.C.A. § 1111 (West 1991); 38 C.F.R. § 3.304 (1999); Crowe v. Brown, 7 Vet. App. 238, 245 (1994). On review of the examinations coincident with enlistment and subsequent thereto, none of the examiners in- service concluded that the migraine headaches with syncope and the left knee pain pre-existed service. Therefore, in regards to these conditions, the veteran is presumed to have been in sound condition on enlistment for service. And, the question becomes whether these conditions were incurred in- service. I. Migraine headaches with syncope The veteran asserts that while working on an aircraft fuselage in 1975 "?", he slipped off the top of the craft and hit his head on the wing of the aircraft causing pain and severe headaches. He contends that he still has pain. He reports that he had headaches [occasionally] before entering service; he characterized these as normal. Service medical records for the period of July 1973 to November 1975 reflect that the veteran's head and neurologic status were evaluated as normal on enlistment. The veteran denied having or ever having had severe or frequent headaches on the July 1973 report of medical history. Prior to April 1974, headaches were associated with upper respiratory infection. Thereafter, an April 1974 report of medical history reflects frequent or severe headache. The veteran was referred for an ophthalmologic consultation for difficulty reading and headaches. He was issued an eye glass prescription. The service medical records dated between May 1974 and January 1975 to include a neurology clinic consult dated in August 1974 reflect that the veteran was evaluated on numerous occasions for multiple instances of fainting or blacking out, severe headaches, blurring of vision with bright spots, syncope, and second degree migraine headaches that were medicated with Bellergal two times a day. In brief, the head and neurologic evaluations were normal for this period. A May 1974 skull series to evaluate blacking out spells plus severe headache was negative. The June 1974 electroencephalogram (EEG) was within normal limits. A July 1974 physical profile reflects dizziness and syncope, etiology unknown and that the veteran should not work in high places. The diagnostic impressions included blacking out spell and headache, rule out head pathology, and probable functional; doubt organic pathology; syncope "?" secondary to migraine headaches; frequent headaches, second degree migraine headaches; and dizziness and fainting spells due to headaches, cause unknown. A medical evaluation Board was recommended in September and December 1974. In December 1974, the veteran felt that getting out of the air force would help. Service medical records for the period from January 1975 and November 1975 to include internal medicine consults reflect ongoing evaluations and treatment of migraine headaches, head trauma in 1974, and syncope/ unconsciousness. The neurologic examinations during this period were within normal limits. During this period, the veteran medicated with Bellergal and Norflex for the headache. In pertinent part, the January and May 1975 internal medicine narrative summaries reflect that the veteran had symptoms of bifrontal and bitemporal headaches, dizziness, and passing out spells for approximately five years. The symptoms included occipital pounding headaches that occurred on an almost daily basis and are accompanied approximately two to three times a month with episodes of frank syncope. The veteran reported that, in the last 3 years, tinnitus, blurred vision, and dizziness often preceded the headaches. He reported passing out in October 1974 for two or three hours. He denied any injury associated with that episode. Since that time, the veteran had 10 or 12 more episodes of passing out, usually associated with postural change and never involving a fall. Most of his episodes occurred at work. It was recommended that the veteran should undergo a medical evaluation Board to determine his level of disability and/or whether he should be maintained on active duty in the service. Multiple transmittals dated in February and March 1975 reflect, in essence, schedule medical evaluation Board. The May 1975 internal medicine narrative summary reflects that the veteran did not require a medical evaluation Board. A physical profile serial report dated in May 1975 contained no individual restrictions for simple syncope with possible postural relationship. The diagnoses during this period included syncope of unknown etiology and migraine headaches; and headache, secondary to muscle spasm and simple syncope with possible postural relationship. The September 1975 report of medical examination completed for separation under AFM 39-12 reflect that the head and neurologic evaluations were normal. The veteran separated from service in November 1975. A private medical record from Dr. Schlosser dated in October 1996 reflects that the veteran has had migraine type headaches for many years and these have been stable. The veteran usually gets an aura with some scotomata and then the headaches come in fairly severely at times. He gets these [migraine type headaches] multiple times per week. Sometimes the veteran "gets nauseated" but does not vomit. Dr. Schlosser noted that these certainly sound like vascular headaches. A trial of Cafergot was recommended. The January 1997 VA joints examination reflects that the veteran fell from the fuselage of an aircraft striking the occipital area of his head against the wings of the plane in January 1975. He immediately experienced occipital head pain and light-headedness and the symptoms persisted. The injury occurred at Edwards Air Force Base. The veteran was transferred to Travis Air Force Base for further evaluation one month after the injury. Frequent headaches have persisted since the head injury. The headaches have not changed significantly in frequency or severity since 1975. The diagnostic impression included, inter alia, that the veteran has experienced recurrent headaches, most severe in the frontal area of the head, since the January 1975 head injury and the headaches are believed to be of the post traumatic type. The February 1998 VA examination reflects that the veteran sustained an injury to the occipital area of his head in January 1975, as noted in the previous compensation and pension examination. The veteran underwent a neurologic work-up at Travis Air Force Base, approximately one week following the above injury. The veteran has experienced recurrent headaches, most severe over the frontal area, since the 1975 injury. Nausea, vomiting, and impaired vision are frequently associated with the headaches and the headaches are often relieved by Imitrex. Lightheadedness and, at times, near syncope is associated with the severe head pain. The veteran's headaches are believed to be of the migraine type with a post traumatic headache component related to the January 1975 injury. Based on a review of the evidence of record, entitlement to service connection for migraine headaches with syncope episodes has been established. The record overall establishes that the veteran's currently diagnosed migraine headaches with a post traumatic headache component initially began in-service and is attributable to head trauma. See Caluza v. Brown, 7 Vet. App. 498 (1995); 38 C.F.R. § 3.303. As discussed above, service medical records show that the veteran sustained head trauma and developed severe headaches thereafter with syncope episodes, which required medical evaluation and treatment. It is also noted that diagnoses of syncope, etiology unknown, and migraine headaches; symptoms of bifrontal and bitemporal headaches preceded by tinnitus, blurred vision, and dizziness; and headache secondary to muscle spasm and simple syncope with a possible postural relationship were documented during his active military service. Additionally, the veteran complained of frequent or severe headaches, dizziness, and fainting spells. Further, the Board recognizes the examiner's opinion in 1998 which attributes the veteran's headaches to be the migraine type with a post traumatic headache component related to the in- service injury. Considering the veteran's service medical reports and the post-service medical opinion which attributes the veteran's current migraine headaches with syncope episodes to in-service events, the Board finds that entitlement to service connection has been established. See 38 U.S.C.A. § 1110, 5107. In this case, the Board acknowledges the absence of clinical reports demonstrating treatment following military service. However, the Board emphasizes that the record overall establishes that the veteran's migraine headaches with syncope episodes had its onset in-service and is more properly attributable to in-service causes. In this regard, the Board emphasizes that the first medical evidence post- service, a private medical record of Dr. Schlosser dated in October 1996, reflects that the veteran has had migraine type headaches for many years which had been stable and that he usually got an aura with some scotomata, which is consistent with clinical findings in-service. Despite the period of time between service and the next medical evidence of record, the aforementioned evidence indicates that the veteran experienced symptomatology associated with the migraine headaches since service. The Board stresses that section 3.303(b) requires continuity of symptomatology, not continuity of treatment. See Cartright v. Derwinski, 2 Vet. App. 24 (1991). As long as the evidence of record shows that the veteran's current migraine headaches with syncope episodes are causally related to in-service events or treatment, entitlement to service connection may be established. See Caluza and Epps, both supra. As reasoned above, the competent evidence of record supports the veteran's assertions which attribute his current migraine headaches with syncope episodes to service. The record shows that during service the veteran sustained head trauma in 1974, that he experienced migraine headaches with syncope episodes on multiple occasions, that he received treatment and hospitalization, and that the veteran still complained of frequent or severe headaches, dizziness or fainting spells at separation from service. Moreover, the February 1998 VA examination reflects that the headaches are believed to be of the migraine type with a post traumatic headache component related to [an in-service] injury. Considering the foregoing evidence of record which supports that the veteran sustained a head trauma in-service, that the onset of his migraine headaches with syncope occurred during his military service, and that the veteran has migraine headaches with syncope now, together with the examiner's belief that the migraine headaches are related to the in- service head injury, the Board concludes that the evidence supports the claim of entitlement to service connection for migraine headaches with syncope episodes. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). II. Left knee injury Service medical records for the period of July 1973 to November 1975 reflect that the lower extremities were evaluated as normal on enlistment. The April 1974 report of medical history reflects complaints of trick or locked knee, that his left leg goes to sleep when standing a long time, and that he was advised to have operation on his knee in 1973. A September 1974 orthopedic consult reflects that the veteran injured his left knee in high school. The veteran did not have his records and the examiner noted that he could not examine them. The note reflects that the knee was initially quite swollen, but recently he has had no problems with the knee, and has had no problems during his air force career. On physical examination, the left knee was within normal limits. The x-ray of the left knee for recurrent dislocations was within normal limits. The impression was normal left knee but cannot rule out quiescent [. . .] derangement. The September 1974 report of medical history reviewed by a corpsman reflects trick knee - see consult. An October 1974 x-ray of the knee for pain and locking of the left knee reflects no evidence of bone or joint pathology. The September 1975 report of medical history together with the report of medical examination signed by medical corpsmen reflect that the lower extremities were evaluated as normal, that he was advised to have the left knee repaired for torn cartilage in 1970, that the left knee locked - no problems over the past few years, and that the knee was within normal limits - see consult. The private medical records of Dr. Schlosser dated for the period of January 1990 to December 1996 make no mention of a left knee injury. The January 1997 VA joints examination reflects that the veteran sustained a twisting injury to his left knee in the summer of 1974 while coming down a flight of stairs. The left knee immediately became painful and edematous. The veteran recovered from the acute left knee injury over a period of a few weeks, but has experienced intermittent left knee pain, most severe over the anteromedial aspect of the knee, and persistent left knee edema since the 1974 left knee injury. The left knee pain often develops or increases in severity following the onset of cold and damp weather. Following the examination, the examiner opined that the specific cause of the veteran's recurring left knee pain and impaired left leg strength was undetermined. The January 1997 x-ray of the left knee was normal. The February 1998 VA examination reflects that the veteran sustained a left knee injury in the summer of 1974 and that the veteran has experienced frequent knee pain, most severe over the anterior, anterior medial, and anterior lateral aspects of the knee since the injury. The examiner referenced the January 1997 VA examination noting that the left knee x-ray was normal. He added that patellar femoral syndrome is believed to be the cause of the veteran's recurring left knee pain. The veteran's impaired left lower extremity strength is believed to be secondary to the persistent left knee pain. The veteran contends that while walking down a flight of stairs in 1974 or 1975, he slipped and fell down wrenching his left knee causing severe pain and numbness of his lower extremity. His knee swells and is numb from the knee joint down. The knee is aggravated while using stairs, ladders, areo stands, and standing. The Board accepts that while the veteran is competent to provide an account of the symptoms he has experienced, he is not competent to provide a medical diagnosis. See Hayes v. Brown, 9 Vet. App. 67, 72 (1996); Falzone v. Brown, 8 Vet. App. 398, 403 (1995). However, he is capable of describing his symptoms. As noted earlier, there were medical observations in-service referable to trick knee, locked knee, and recurrent dislocations. The Board also observes that the September 1974 consult noted that quiescent [. . .] derangement could not be ruled out. It is noted that for more than 22 years after service there are no complaints or references to a left knee injury in the post- service clinical records. See Cartright v. Derwinski, 2 Vet. App. 24 (1991) (Section 3.303(b) requires continuity of symptomatology, not continuity of treatment). Nevertheless, in February 1998 by VA examination, his chronic left knee pain since service is diagnosed as patellar femoral syndrome and that his left lower extremity strength is believed to be secondary to the left knee pain. In this regard, the veteran has presented credible medical evidence of a current disability diagnosed as patellar femoral syndrome that is related to his period of military service. See Caluza v. Brown, 7 Vet. App. 489 (1995); 38 C.F.R. § 3.303(d). Accordingly, service connection for a left knee injury diagnosed as patellar femoral syndrome is warranted. ORDER Service connection for bilateral hearing loss is denied. Service connection for right elbow pain, diagnosed as right elbow epicondylitis, is granted. Service connection for migraine headaches with syncope episodes is granted. Service connection for patellar femoral syndrome of the left knee is granted. Deborah W. Singleton Member, Board of Veterans' Appeals