Citation Nr: 9918935 Decision Date: 07/12/99 Archive Date: 07/20/99 DOCKET NO. 95-27 960 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Los Angeles, California THE ISSUE Entitlement to service connection for a bilateral knee disorder, asthma, and jungle rot and a skin rash claimed as secondary to Agent Orange (AO) exposure. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD K.L. Salas, Associate Counsel INTRODUCTION The veteran had active military service from January 1969 to December 1970. This appeal arose from a November 1993 rating decision by the Department of Veterans Affairs (VA) Los Angeles, California Regional Office (RO). The RO denied the veteran's claims for entitlement to service connection for a "bilateral knee condition," asthma, jungle rot, an "Agent Orange rash," and post-traumatic stress disorder (PTSD). The RO granted entitlement to service connection for PTSD with assignment of a 30 percent evaluation when it issued a rating decision in February 1995. Though the veteran timely appealed the above determination and was issued a statement of the case (SOC) in January 1996, he did not file a substantive appeal until June 1996. By letter dated in August 1996 the RO notified the veteran that his appeal was closed since he did not file a timely substantive appeal. The issue of entitlement to an increased evaluation for PTSD was inadvertently listed on the title page of the February 1997 Board of Veterans' Appeals (Board) remand to the RO to afford the veteran a requested hearing before a traveling Member of the Board. In September 1998, the veteran withdrew his request for a Board hearing, and in lieu of that hearing requested a hearing before RO personnel. In November 1998, the RO issued a rating decision increasing the 30 percent evaluation for PTSD to 50 percent effective August 25, 1997. In his May 1999 statement on behalf of the veteran, the representative at the Board expressed disagreement with the November 1998 rating decision wherein the RO granted entitlement to an increased evaluation for PTSD. This issue is addressed in the remand portion of the decision. The veteran's representative also argued that the veteran may be entitled to a total disability rating for compensation purposes based on individual unemployability. This issue has been neither procedurally prepared nor certified for appellate and is referred to the RO for initial consideration and appropriate action. FINDING OF FACT The claim for entitlement to service connection for a bilateral knee disorder, asthma, jungle rot and a skin rash claimed as secondary to AO exposure is not supported by cognizable evidence showing that the claim is plausible or capable of substantiation. CONCLUSION OF LAW The claim for entitlement to service connection for a bilateral knee disorder, asthma, jungle rot and a skin rash claimed as secondary to AO exposure is not well grounded. 38 U.S.C.A. § 5107 (West 1991). REASONS AND BASES FOR FINDING AND CONCLUSION Factual Background The veteran's DD-214 shows that his decorations include a Combat Action Ribbon, Vietnam Service Medal, and a Vietnam Campaign Medal. Personnel forms note that the veteran participated in operations against the enemy insurgent forces in the Republic of Vietnam. On induction in January 1969 the veteran had no abnormality of the feet, skin, lungs or knees. He denied a history of any such abnormality. A chest x-ray was normal. In October 1969 the veteran was seen for trouble breathing in the evening from asthma. He reported an attack three days before. He reported a history of asthma since 9th grade. He reported two attacks in Vietnam. The impression was asthma by history. He was provided with medication. In December 1969 the veteran was hospitalized for swelling of the left foot with ulcerations and crusting over the dorsum of the left foot. He was treated with Griseofulvin and Desenex without improvement. Examination showed crusted lesions on the dorsal surfaces of the left hand and the left foot. The left foot was swollen and tender. Lab testing found a staph aureus infection. Chest x-ray was within normal limits. Treatment consisted of erythromycin, warm moist dressings and Viocort. He was to continue using Viocort at night and D-sorb powder during the day. On the discharge examination from November 1970 the only skin abnormalities noted were scars or marks. It was noted that there were no sequelae of the staph infection of the foot. There was no finding of any "jungle rot" of the feet, knee trouble, skin rash or asthma. The veteran reported a prior history of asthma, foot trouble and swollen or painful joints. He denied a trick or locked knee. On the back of the form he reported that he had jungle rot and two wounds that did not need hospitalization. Records of the veteran's VA hospitalization from September 1993 to November 1993 show treatment of a fungal infection of the feet. The veteran had VA domiciliary care from December 1993 to April 1994. While the hospitalization was for drug and alcohol abuse and PTSD, it was noted on the discharge report that he also had "tinea pedis 'jungle rot.'" During that domiciliary stay, the veteran also reported other physical problems. He related that he had a childhood history of asthma but noted that he was never hospitalized for asthma, and his last episode was in 1969. He also reported a severe injury to his knees in Vietnam, and a constant rash of the feet that he considered to be "jungle rot." He did not report any chest symptoms. It was noted that a chest x-ray in 1993 was negative. He reported knee stiffness with pain. Examination of the chest was negative. The knees were within normal limits. On examination of the skin, there was a rash on the feet. There was foot dermatitis with hyperpigmentation and hyperkeratotic bands that were considered contact dermatitis. In January 1994 the veteran was seen for a fungal foot infection. He was given ointment, "Acufour" and Betadine soaks for heel keratitis and blisters. The discharge report noted knee stiffness with pain. Examination of the lungs was normal. The knees were also within normal limits. Aside from healed scars there was only a rash on the feet. The veteran was provided with a VA AO evaluation in April 1994. He reported that a rash on his feet started in 1970 prior to military discharge. He stated that he was cured but that the symptoms recurred. He reported that the symptoms would appear every two years. He stated that under his feet he would have bumps, spots, pus, thick skin, and crusting. On the tops of his feet he would have blemishes and crusting. He reported pain with the rash. He also reported that he developed knee pain when he jumped into a fox hole during battle and his knees locked. He reported swelling of both knees. He denied being seen for that problem. On examination, the lungs were clear to auscultation. No abnormality of the knees or of the feet was reported. However, it was noted that in a letter to the veteran regarding the results of his examination it was stated that the examination showed a rash on both feet. X-rays reportedly showed both knees to be within normal limits. A chest x-ray was normal. The veteran was hospitalized from April 1994 to August 1994. The principal reason for the admission was for evaluation of PTSD. However his knees, skin, and lungs were also evaluated. In May 1994 referrals were made for evaluation of skin rashes and a history of asthma. On a dermatology evaluation that month, the veteran reported a rash on his feet for one year. There were hyperkeratotic plaques and fissures on his feet, and on the soles between the toes. The assessment was tinea pedis. In May 1994 the veteran reported that he had a history of asthma with exacerbation in the service. He denied any recent problems with asthma. He reported some coughing. He reported that he smoked half a pack of cigarettes a day for 30 years but was down from two packs per day. The chest was clear with no wheezing. The assessment was a history of asthma as a child that was currently stable. A Vancenase inhaler was prescribed. On the same visit, the veteran reported a history of seasonal skin rashes involving the face over the maxilla bilaterally and the frontal region as well as the bottom of the feet. It was noted that he was currently asymptomatic. He reported that rashes consisted of pinpoint bumps and erythema that would resolve over a few days. Examination of the skin showed no lesions. On follow-up evaluation of the lungs in June 1994, the veteran gave essentially the same history as previously. He reported that he was asymptomatic but then complained of some mild shortness of breath. The lungs were normal. The only impression was a 50 pack-year history of smoking, currently asymptomatic. The veteran also had follow-ups for tinea pedis in June 1994. On the first visit there were scaly plaques on the soles of both feet. The assessment was tinea pedis. Later that month both feet were hyperkeratotic with slight scaling. The assessment was again tinea pedis. The veteran also underwent an evaluation of his knees in June 1994. He reported bilateral knee pain, left worse than right since 1970 when he had an injury in Vietnam. He reported left knee symptoms including popping, clicking, medial pain, swelling and giving way approximately every other month. On the right he reported mainly anterior pain that was activity related. After examination and x-rays, the assessment was a possible left meniscal tear. X-rays showed bilateral early degenerative changes. At the end of June the veteran was seen again in the allergy clinic. He was still smoking. The lungs were clear. No diagnosis of asthma was made. The doctor advised him to discontinue Vancenase. In July 1994 the veteran underwent a left knee arthroscopy with debridement of the left medial meniscus and debridement of hypertrophied synovium. It was noted that he had a long history of left knee medial joint line pain with occasional popping, swelling, and buckling. The surgery found degenerative changes, synovitis, and fraying of the medial meniscus. The veteran was transferred from the hospital into a domiciliary PTSD program from August 1994 to March 1995. During that time there was treatment of the lungs, skin and knees. A report from the day of admission early in August 1994 noted that the veteran had a left knee arthroscopy. It was also noted that he had dermatitis for which he was using numerous topical medications. He also reported asthma without medications, and "jungle rot." A record from the same month showed that the veteran reported a pruritic rash for three days. He denied any pain. The symptoms started with a bump on the shoulder and then reportedly spread. Examination was consistent with herpes zoster. That month, the veteran was also seen for some asthma or wheezing. The lungs were clear. On a follow-up dermatology referral, the veteran's tinea pedis was much better with treatment. He had xerotic scale and interdigital maceration. The assessment was tinea pedis. In October 1994 the veteran was undergoing physical therapy on his left knee. On a follow-up for evaluation of tinea pedis in October 1994, the veteran still had interdigital maceration and scale. The impression was tinea pedis. He also had some papules on his cheeks. The impression was acne. In a letter submitted in October 1994 the veteran listed several medications that had been prescribed for fungus of the feet. He stated that the medications would work for only a short period of time before symptoms would come back. He stated that the foot fungus was incurred in Vietnam. The veteran underwent a right knee arthroscopy in November 1994. Operative indications included a history of right knee pain and radiographs showing mild degenerative changes. Operative findings included medial meniscus tears and chondromalacia. No opinion on etiology was given. On follow-up a little over a week after the operation, the veteran had some pain with weight bearing, swelling and limitation of right knee flexion. The veteran had a dermatology follow-up in November 1994 for tinea pedis. He had scaly feet with interdigital maceration. The veteran testified at a hearing at the RO in November 1994. He reported that when in Vietnam, his feet got wet and a staph infection with cellulitis developed. He reported that with treatment it went away but then kept coming back. The veteran also felt that he was exposed to AO in Vietnam. He reported that planes would spray when he was there. He reported that his current symptoms included a rash on the chest and around the neck. He reported that despite creams the rash would come and go. Later he testified that the rash was on his neck, chest, and calf. He reported that he had symptoms four times in 1994. He reported that he would get it about the same frequency every year. He stated that the rash would last about two and a half to three weeks. He stated that the rash was different from "jungle rot," which was between his toes, on the bottoms of his feet, and on his heels. He reported soaking his feet with Betadine and then using creams. He stated that his foot symptoms would occur every two to three years. He felt that this was the same problem he had in service, and he testified that he received the same treatment in service. With regard to asthma, he reported that it was diagnosed in boot camp. He denied any treatment. He testified that he had an attack before a battle in service. In fact he felt that combat alleviated his symptoms. He testified that he would get "short winded." He denied any treatment for approximately 24 years after service. He admitted to taking some cough drops. He reported that he had recently received treatment including inhalers. He was told that he was allergic to "almost everything." With regard to his knees, he reported that during a battle in service he jumped into a hole and his knees locked. He testified that he was not allowed to be evacuated for treatment. He testified that they continued to hurt after that incident. He denied any treatment of his knees in service. He reported that his knees were evaluated in 1972 or 1973 at a hospital in Pasadena, California, and that a doctor wanted to operate. He denied other treatment of the knees until recent surgery. The veteran reported that he "injured" his knees after service but only described symptoms provoked by stooping and getting up. In December 1994, the veteran reported a remote knee injury 25 years before. He reported that he had no change in his preoperative right knee symptoms. He was still complaining of anterior knee pain with use of stairs, but he denied giving way, catching or locking. He had full active and passive range of motion. The impression was chronic right knee pain. The physician also noted probable patellofemoral syndrome and osteoarthritis. In January 1995 the veteran continued to complain of bilateral knee pain. The assessment was chronic bilateral knee pain. A psychiatric report pending the veteran's discharge from the PTSD program noted Axis III diagnoses of tinea pedis and right knee pain. On the discharge report from March 1995, diagnoses included PTSD, asthma, dermatitis, and status post right knee arthroscopy. It was noted that the veteran had undergone a left knee arthroscopy in July 1994. In a summary of the domiciliary treatment it was noted that he was treated for herpes zoster of the right shoulder area in August 1994, which resolved without sequelae. He completed a course of physical therapy for the knees and there were no sequelae noted from the right knee arthroscopy. The veteran was hospitalized in December 1996 and January 1997 for depression and PTSD. It was noted that during this hospitalization he had a dermatofibroma, and tinea. VA examinations of the skin, lungs, and joints were conducted in August 1997. The veteran reported that his knees locked up on him when he fell into a hole in service. He reported that he endured many years of pain and had arthroscopic surgery in 1994 through a VA Medical Center (VAMC). The veteran reported treatment with aspirin and knee wraps. The diagnosis after an examination and x-rays was mild old osteoarthritis bilaterally with large right knee effusion, probable left small left knee effusion, mild range of motion deficits, and moderately severe pain on range of motion examination. With regard to the skin, the veteran reported that in Vietnam he developed a skin rash on the back and legs. He stated that the rash would come and go, and that the last break out was three months earlier. He reported that the pruritic rash appeared to be weather dependent and he stated that he was told that it was similar to eczema. He stated that he would not use medication on the rash. There was no rash on examination and the skin was clear. The veteran expressed no complaints pertaining to the feet. On a psychiatric examination he reported a history of tinea pedis. After examination of the lungs a diagnosis was made of historical asthma, presently controlled with over the counter medications. Pulmonary function studies were consistent with a combination of mild restriction, interstitial lung disease (ILD), and mild chronic obstructive pulmonary disease (COPD). It was noted that the veteran was a smoker. The veteran testified at a hearing at the RO in January 1999. He reported that prior to service he had asthma attacks. He testified that he had a mild case. He stated that he used an inhaler but not that much. He also reported that he used a poultice and Vicks. Later in his testimony, he testified that when he was a child he had four or five attacks per summer. He stated that he had an attack in service but it went away. He stated that he would get "short-winded". He could not say whether or not he had asthma attacks more frequently in service and he denied that he had any physical limitations placed on him in service. He could only recall being treated on one occasion in service for asthma. The veteran stated that he was coughing and self-treating with Ludens, Halls Mentholyptus or Vicks rub when he would feel symptoms coming on. He reported that he did not currently have attacks too often. He stated that he associated them with sudden weather changes and very hot weather. He felt that the "bad air" in California was also contributing. He reported that he got inhalers through VA in 1994, but was not using them. With regard to jungle rot, the veteran reported that he was mostly in the field in Vietnam. He reported that he "stayed in water" and his feet were constantly wet. He stated that his feet would crack, bleed and swell. He reported he was told that he had cellulitis and a staph infection. He testified that every two or three years his feet would break out. He reported that he would use Aquaphor and Mycelex on his feet. He reported that his symptoms were bad from 1992 to 1994, but were improved with VA treatment. He stated that symptoms came back the last year. He reported that he would change his socks two times a day. He denied any problem prior to service. The veteran testified that he developed a skin rash on his legs, back and neck. He testified he was told that it was cellulitis or staph. He denied any rashes in service. He stated that they started later - in 1971 or 1972. He testified that he would notice symptoms twice a year. He reported that he was given "Keri lotion" through VA. He stated that his symptoms were like hives. He stated that he constantly switched soaps and detergents but continued to have symptoms. He denied a problem prior to service. The veteran testified that prior to service he played sports but never injured his knees. He reported that when in Vietnam he jumped into a hole and hyperextended his knees. He reported that he then had to walk and was not evacuated. He testified that his knees were swollen. He testified that on discharge he told the doctor but he was told that if he complained about his knees he would not be allowed to leave. The veteran reported that a few years later his knees would crack. He testified that later, working as a bricklayer he had knee pain. He was told by doctors that his cartilage was rubbing. He also stated that he had episodes of his leg locking and giving out. He testified that eventually he underwent operations on both knees in 1994 for a meniscus tear. According to the veteran he currently has arthritis in the knees. He reported that one doctor told him that his injury was over 20 years old. Criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110. Service connection connotes many factors but basically it means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. This may be accomplished by affirmatively showing inception or aggravation during service or through the application of statutory presumptions. Each disabling condition shown by a veteran's service records, or for which service connection is sought, must be considered on the basis of the places, types and circumstances of the veteran's service as shown by service records, the official history of each organization in which the veteran served, medical records and all pertinent medical and lay evidence. Determinations as to service connection will be based on review of the entire evidence of record, with due consideration to the policy of VA to administer the law under a broad and liberal interpretation consistent with the facts in each individual case. 38 C.F.R. § 3.303(a) (1998). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, for example, in service will permit service connection of arthritis, first shown as a clear-cut clinical entity, at some later date. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established, there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b) (1998). 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. Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. § 3.303(d) (1998). A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air 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. 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. 38 C.F.R. § 3.306 (1998). If a veteran was exposed to an herbicide agent during active military, naval, or air service, the following diseases shall be service-connected if the requirements of §3.307(a)(6) are met even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of § 3.307(d) are also satisfied: Chloracne or other acneform disease consistent with chloracne; Hodgkin's disease; Multiple myeloma; Non-Hodgkin's lymphoma; Acute and subacute peripheral neuropathy; Porphyria cutanea tarda; Prostate cancer; Respiratory cancers (cancer of the lung, bronchus, larynx or trachea); and Soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e) (1998). A chronic, tropical, prisoner of war related disease, or a disease associated with exposure to certain herbicide agents listed in § 3.309 will be considered to have been incurred in service under the circumstances outlined in this section even though there is no evidence of such disease during the period of service. No condition other than one listed in § 3.309(a) will be considered chronic. The veteran must have served 90 days or more during a war period. Chronic diseases must have become manifest to a degree of 10 percent or more within 1 year (for Hansen's disease (leprosy) and tuberculosis, within 3 years; multiple sclerosis, within 7 years) from the date of separation. 38 C.F.R. § 3.307(a) (1998). The diseases associated with exposure to certain herbicide agents listed at § 3.309(e) shall have become manifest to a degree of 10 percent or more at any time after service, except that chloracne or other acneform disease consistent with chloracne shall have become manifest to a degree of 10 percent or more within a year. 38 C.F.R. § 3.307(a)(6) (1998). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era and has a disease listed at § 3.309(e) shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. The last date on which such a veteran shall be presumed to have been exposed to an herbicide agent shall be the last date on which he or she served in the Republic of Vietnam during the Vietnam era. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. Id. The factual basis may be established by medical evidence, competent lay evidence or both. Medical evidence should set forth the physical findings and symptomatology elicited by examination within the applicable period. Lay evidence should describe the material and relevant facts as to the veteran's disability observed within such period, not merely conclusions based upon opinion. The chronicity and continuity factors outlined in § 3.303(b) will be considered. 38 C.F.R. § 3.307(b) (1998). No presumptions may be invoked on the basis of advancement of the disease when first definitely diagnosed for the purpose of showing its existence to a degree of 10 percent within the applicable period. This will not be interpreted as requiring that the disease be diagnosed in the presumptive period, but only that there be then shown by acceptable medical or lay evidence characteristic manifestations of the disease to the required degree, followed without unreasonable time lapse by definite diagnosis. The consideration of service incurrence provided for chronic diseases will not be interpreted to permit any presumption as to aggravation of a preservice disease or injury after discharge. 38 C.F.R. § 3.307(c) (1998). It has been held that where a claim is filed under a presumptive provision, the veteran is not precluded from establishing service connection with proof of actual direct causation. Combee v. Brown, 34 F. 3d 1039 (Fed. Cir. 1994). That is to say that if service connection is not supported under a presumptive paragraph a determination must be made whether the disease was incurred in service under 38 C.F.R. § 3.303 (or aggravated by service if the disease preexisted service as provided in 38 C.F.R. § 3.306). He could also seek presumptive service connection on another ground if applicable. Satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection if the evidence is consistent with the circumstances, conditions or hardships of such service even though there is no official record of such incurrence or aggravation. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Section 5107 of Title 38, United States Code unequivocally places an initial burden upon the claimant to produce evidence that his claim is well grounded; that is, that his claim is plausible. Grivois v. Brown, 6 Vet. App. 136, 139 (1994); Grottveit v. Brown, 5 Vet. App. 91, 92 (1993). For a claim for service connection to be well grounded, there must be competent evidence of a current disability in the form of a medical diagnosis, of incurrence or aggravation of disease or injury in service in the form of lay or medical evidence, and of a nexus between in service injury or disease and current disability in the form of medical evidence. Caluza v. Brown, 7 Vet. App. 498, 506 (1995). In addition, in the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The second and third elements of the Caluza test can also be satisfied by evidence that a condition was "noted" in service or during an applicable presumptive period; evidence showing post service continuity of symptomatology; and medical or, in certain circumstances, lay evidence between the present disability and the post service symptomatology. Savage v. Gober, 10 Vet. App. 488 (1997). Where the determinative issue involves causation or a medical diagnosis, competent medical evidence to the effect that the claim is possible or plausible is required. Murphy v. Derwinski, 1 Vet. App. 78, 81 (1990). The claimant does not meet this burden by merely presenting his lay opinion because he is not a medical health professional and does not constitute competent medical authority. Espiritu v. Derwinski, 2 Vet. App. 492 (1992). Lay assertions cannot constitute cognizable evidence, and as cognizable evidence is necessary for a well-grounded claim, Tirpak v. Derwinski, 2 Vet. App. 6-9, 611 (1992), a claim based only on the veteran's lay opinion is not well grounded. In determining whether a claim is well grounded, the claimant's evidentiary assertions are presumed true unless inherently incredible or when the fact asserted is beyond the competence of the person making the assertion. King v. Brown, 5 Vet. App. 19, 21 (1993). The United States Court of Appeals for Veterans Claims (the Court) has held that if the veteran fails to submit a well- grounded claim, VA is under no duty to assist in any further development of the claim. 38 U.S.C.A. § 5107(a); Gilbert v. Brown, 5 Vet. App. 91, 93 (1993); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997); 38 C.F.R. § 3.159(a) (1998). See also McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When, after consideration of all of the evidence and material of record in an appropriate case before VA, there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b) (West 1991); 38 C.F.R. §§ 3.102, 4.3 (1998). Analysis Bilateral Knee Disorder With regard to the claim of entitlement to service connection for a bilateral knee disorder, the veteran clearly has a current disability of the knees. The veteran had recurrent complaints with regard to both knees, and knee pathology was identified which required surgery on each knee in 1994. The question is whether this disability can be linked to the veteran's service. The veteran's service medical records do not specifically show an injury to the knees. He reported on discharge that he had swollen or painful joints and two injuries that did not need hospitalization. On the other hand, he also denied a trick or locked knee. However, the veteran engaged in combat in Vietnam. He is the recipient of a Combat Action Ribbon. The veteran's account is that, in essence, he jammed his knees when jumping into a hole during battle. He was in the field and he was deemed not badly injured enough to be evacuated for care. This description of his injury is credible and is consistent with the circumstances and hardships of combat. Therefore the existence of the injury in service is accepted. It is noted that the veteran has always consistently reported the same history of injuring his knees in service. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). Notwithstanding that the veteran had an injury to the knees in service and has a current disability of the knees, his claim is not well grounded because the evidentiary record lacks any competent medical evidence of a nexus between his inservice injury and disability shown many years after service. Asthma The evidence shows the veteran has reported experiencing attacks of lung symptomatology that he characterized as attacks of asthma prior to service. It was the veteran's understanding that he had asthma prior to service - notwithstanding that he was apparently asymptomatic on the day he underwent his service entrance examination. The veteran has repeatedly admitted to a history of asthma prior to service dating to his youth. The Board's review of the evidentiary record discloses that regardless of whether the veteran clearly had asthma prior to service, there is no competent evidence that any preexisting respiratory symptomatology was permanently worsened or aggravated as a result of his military service. There is no evidence of chronic asthma in service and there is no medical evidence establishing a nexus between any current respiratory disability no matter how diagnosed and his military service on any basis. Service medical records show that in October 1969 the veteran was seen for trouble breathing in the evening from asthma. He reported an attack three days before. He reported a history of asthma since 9th grade. He only reported two attacks total. The impression was asthma by history. There was no further treatment shown. During his hearing testimony the veteran denied any serious or chronic symptoms in service, and he denied that he had any significant limitation or any medical profile while in service. Not only was there minimal evidence of symptomatology or treatment in service, there is no showing of treatment for chronic asthma after service. The veteran reported on a number of occasions during VA treatment in 1993 and 1994 that he had asthma. He also reported that he had an exacerbation in service. However, the veteran had very minor findings and a Vancenase inhaler was discontinued. There was no medical opinion from any of the treatment providers that the veteran had any identifiable residuals attributable to his military service. There was no opinion of a worsening of his underlying condition in service or thereafter. The mere existence of symptoms attributable to asthma in service and then again many years after service is not sufficient to show inception or aggravation. A temporary flare up of symptomatology without evidence of worsening of the underlying condition does not constitute aggravation for the purpose of entitlement pursuant to 38 C.F.R. § 3.306. Hunt v. Derwinski, 1 Vet. App. 292 (1991). The veteran has not shown that he had asthma attacks incurred as a result of action against the enemy in Vietnam. His testimony as a whole was considered as were his service records. The service records do not suggest disabling attacks of asthma; nor do they suggest asthmatic attacks provoked by combat. Rather they show some mild manifestations of asthma in service that did not warrant any limitations or physical profile. Given the mild post service manifestations of asthma reported by the veteran and the relatively little treatment shown many years post service, the Board concludes that asthma was not incurred in or aggravated by service. The is no competent medical evidence of record linking asthma to service on any basis. Jungle rot, skin rash The service records show that treatment of the feet in service was for a staph infection of the foot. While it appears that the disease was treated as if a fungus at first, and on discharge the veteran reported that he had "jungle rot," the fact remains that the veteran's foot disorder in service was ultimately identified as a staph infection, and no residuals of that infection were identified at the time of the veteran's discharge from service. The veteran has contended that jungle rot of the feet has continued after service. There is no evidence of treatment until many years after service to support the veteran's account of continuing symptoms. However, it is clear from the VA treatment records in the claims folder that the veteran has had chronic problems with tinea pedis - a fungal infection - during the 1990s. The veteran's claim for entitlement to service connection for jungle rot (to include residuals of a staph infection and tinea pedis) is not well grounded for two reasons. First, there were no complaints or findings of present disability in the most recent medical records or on the VA examination report. Without a present disability there cannot be a claim for entitlement to service connection. Brammer. Second, there has been no competent medical evidence associating tinea pedis (the most recent skin disease affecting the feet shown in the evidentiary record) with the veteran's service to include his staph infection in service. There is no showing of a diagnosis of chloracne or acneform disease of the feet consistent with chloracne (and certainly not within one year after service) to trigger the presumptive service connection provisions of 38 C.F.R. § 3.307 and 38 C.F.R. § 3.309(e). As for the claim for entitlement to service connection for a skin rash claimed as secondary to AO exposure, there was only a showing of a staph infection of the foot and hand in service. There was no showing of any other skin disease in service. The veteran reported skin rashes shortly after service but there is no evidence that these rashes were subsequently diagnosed or identified as chloracne or any other acneform disorder consistent with chloracne to trigger the presumptive service connection provisions in 38 C.F.R. § 3.307 and 38 C.F.R. § 3.309(e). The claim for entitlement to service connection for a skin disorder is not well grounded for two reasons. First, on the most recent VA examination, no skin rash or other disease was found. Therefore the claim for entitlement to service connection for a skin disorder is not well grounded. Brammer. Second, it is noted that treatment records from the 1990s showed some acne of the face and herpes zoster. None of the physicians who evaluated the veteran related these symptoms to the veteran's service. In essence, the veteran's claim for entitlement to service connection for a bilateral knee disorder, asthma, jungle rot, and a skin rash claimed as secondary to AO exposure is based solely on his lay opinion. While a lay person may report his symptomatology, he does not have the competency of a trained health care professional to express opinions as to diagnosis and/or etiology of a disorder. Assertions as to these matters are therefore not presumptively credible. King v. Brown, 5 Vet. App. 19, 21 (1993). As it is the province of trained health care professionals to enter conclusions that require medical opinions as to causation, Grivois, the veteran's lay opinion is an insufficient basis upon which to find his claim well grounded. Espiritu. Accordingly, as a well-grounded claim must be supported by evidence, not merely allegations, Tirpak, the appellant's claim for entitlement to service connection for a bilateral knee disorder, asthma, jungle rot and a skin rash claimed as secondary to AO exposure must be denied as not well grounded. It appears that the RO denied the veteran's claim on the merits. The RO did not specifically conclude that the veteran's claim was not well grounded. To the extent that the Board considered and denied the appellant's claim for entitlement to service connection for a bilateral knee disorder asthma, jungle rot and a skin rash claimed as secondary to AO exposure on a ground different from that of the RO, the appellant has not been prejudiced by the decision. This is because to the extent that the RO treated the claim as well grounded, the RO accorded the appellant greater consideration than his claim in fact warranted under the circumstances. Bernard v. Brown, 4 Vet. App. 384 (1993). In light of the implausibility of the appellant's claim and his failure to meet his initial burden in the adjudication process, the Board concludes that he has not been prejudiced by the decision to deny his appeal for service connection for a bilateral knee disorder, asthma, jungle rot and a skin rash claimed as secondary to AO exposure. The Board further finds that the RO has advised the appellant of the evidence necessary to establish a well grounded claim, and he has not indicated the existence of any post service medical evidence that has not already been obtained that would well ground his claim. McKnight v. Gober, 131 F.3d 1483 (Fed. Cir. 1997); Epps v. Gober, 126 F.3d 1464 (Fed. Cir. 1997). As the claims for service connection for a bilateral knee disorder asthma, jungle rot and a skin rash claimed as secondary to AO exposure are not well grounded, the doctrine of reasonable doubt has no application to the veteran's case. ORDER The veteran not having submitted a well-grounded claim of entitlement to service connection for a bilateral knee disorder, asthma, jungle rot and a skin rash claimed as secondary to AO exposure, his appeal is denied. REMAND This claim must be afforded expeditious treatment by the RO. The law requires that all claims that are remanded by the Board or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See The Veterans' Benefits Improvements Act of 1994, Pub. L. No. 103-446, § 302, 108 Stat. 4645, 4658 (1994), 38 U.S.C.A. § 5101 (West Supp. 1999) (Historical and Statutory Notes). In addition, VBA's Adjudication Procedure Manual, M21-1, Part IV, directs the ROs to provide expeditious handling of all cases that have been remanded by the Board and the Court. See M21-1, Part IV, paras. 8.44-8.45 and 38.02-38.03. As noted in the introduction above, when the RO issued its November 1998 rating decision, it allowed a 50 percent evaluation for PTSD effective August 25, 1997. The veteran's representative expressed disagreement with this evaluation when submitting a statement on behalf of the veteran to the Board in May 1999. Failure to issue a SOC is a procedural defect requiring a remand. Godfrey v. Brown, 7 Vet. App. 398 (1995). However, an appeal shall be returned to the Board only if perfected through filing of a timely substantive appeal. Smallwood v. Brown, 10 Vet. App. 93 (1997). Therefore, to ensure that the veteran is afforded due process, 38 C.F.R. § 3.103(a) (1998), the Board is deferring adjudication of this issue pending a remand to the RO for further development as follows: The RO should issue an SOC and advise the veteran of the requirements necessary to perfect a timely appeal if he wishes appellate review. Thereafter, the case should be returned to the Board for further appellate review, if otherwise in order. By this remand, the Board intimates no opinion as to any final outcome warranted. No action is required of the veteran until he is notified by the RO. RONALD R. BOSCH Member, Board of Veterans' Appeals