Citation Nr: 1300840 Decision Date: 01/09/13 Archive Date: 01/16/13 DOCKET NO. 07-30 508 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for myoclonus, including as due to herbicide exposure. 2. Entitlement to service connection for a bilateral foot skin disorder (i.e., rashes, swelling, and dislocation), including as due to herbicide exposure and as secondary to service-connected diabetes mellitus, type II. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Kristi L. Gunn, Counsel INTRODUCTION The Veteran served on active duty from December 1965 to September 1967 and from December 1967 to November 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. In September 2009, the Veteran testified at a video conference hearing before a Veterans Law Judge. A copy of the transcript is of record. In December 2009, the Board remanded the claims to the agency of original jurisdiction for additional development. The case was returned to the Board for further appellate review. In June 2012, the Board requested opinions from Veterans Health Administration (VHA) medical experts. VHA opinions were received in July 2012 and incorporated into the record. The Veteran and his representative were provided a copy of the VHA opinions, and given sixty days to respond. In November 2012, the Veteran indicated that he had no further argument or evidence to submit, and he wished the Board to immediately proceed with the adjudication of his appeal. Therefore, the Board will consider the current evidence of record in deciding the appeal. FINDINGS OF FACT 1. All relevant evidence necessary for an equitable disposition of the Veteran's appeal has been obtained. 2. There is no probative evidence that demonstrates that the Veteran's myoclonus is causally related to his active military service. 3. There is no probative evidence that demonstrates that the Veteran's bilateral foot skin disorder is causally related to his active military service; nor is it caused or aggravated by service-connected diabetes mellitus, type II. CONCLUSIONS OF LAW 1. Myoclonus was not incurred in or aggravated by active service, nor may such a disability be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2012). 2. A bilateral foot skin disorder was not incurred in or aggravated by active service, may not be presumed to have been, and is not proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Board notes the enactment of the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), in November 2000. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, and 5107 (West 2002 & Supp. 2011). To implement the provisions of the law, VA promulgated regulations codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The VCAA and its implementing regulations include, upon the submission of a substantially complete application for benefits, an enhanced duty on the part of VA to notify a claimant of the information and evidence needed to substantiate a claim, as well as the duty to notify the claimant of what evidence will be obtained by whom. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In addition, they define the obligation of VA with respect to its duty to assist a claimant in obtaining evidence. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The Board notes that 38 C.F.R. § 3.159 was revised, effective May 30, 2008. See 73 Fed. Reg. 23353-56 (Apr. 30, 2008). The amendments apply to applications for benefits pending before VA on, or filed after, May 30, 2008. The amendments, among other things, removed the notice provision requiring VA to request the veteran to provide any evidence in the veteran's possession that pertains to the claim. See 38 C.F.R. § 3.159(b)(1). The Board finds that all notification action needed to make a decision as to the claims on appeal has been accomplished. Through an April 2006 notice letter, the Veteran was notified of the information and evidence needed to substantiate his claims of service connection, to include on a direct basis, a secondary basis, and as a result of exposure to herbicide agents such as Agent Orange. The notice letters provided the Veteran with the general criteria for assigning disability ratings and effective dates. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). The Board also finds that the April 2006 notice letter satisfies the statutory and regulatory requirement that VA notify a claimant which evidence, if any, will be obtained by the claimant and which evidence, if any, will be retrieved by VA. See Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002) (addressing the duties imposed by 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b)). In the letter, the Veteran was notified that VA was responsible for obtaining relevant records from any Federal agency and that VA would make reasonable efforts to obtain relevant records not held by a Federal agency, such as from a state, private treatment provider, or an employer. Additionally, the notice letter asked the Veteran to submit medical evidence, opinions, statements, and treatment records regarding his claimed disabilities. Consequently, a remand of the service connection issue for further notification of how to substantiate the claim is not necessary. There is no indication that any additional action is needed to comply with the duty to assist in connection with the issue on appeal. The Veteran's service treatment records have been obtained and associated with the claims file, as have post-service VA outpatient treatment records and private medical records. Additionally, VA also provided the Veteran with VA examinations. The examiners reviewed the Veteran's subjective history, recorded pertinent examination findings, and provided conclusions with rationale. In addition and as previously indicated, opinions from VHA medical experts under the provisions of 38 U.S.C.A. § 7109(a) and 38 C.F.R. § 20.901(a) were obtained in July 2012. There is no indication that further medical opinions are necessary. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). For these reasons, the Board finds that VA has fulfilled the duties to notify and assist the Veteran. II. Service Connection Generally, service connection may be established for disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2011). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The chronicity provision of 38 C.F.R. § 3.303(b) is applicable where the evidence, regardless of its date, shows that the Veteran had a chronic condition in service or during an applicable presumption period and still has such condition. Such evidence must be medical unless it relates to a condition as to which, under the Court's case law, lay observation is competent. Savage v. Gober, 10 Vet. App. 488, 498 (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 be granted where a disability is proximately due to or the result of a service-connected disease or injury. In order for service connection to be granted on a secondary basis, three elements must be present: a current disability, a service-connected disability, and a medical nexus. 38 C.F.R. § 3.310(a) (2012). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. When aggravation of a Veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, the veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). An amendment to 38 C.F.R. § 3.310 implements the holding in Allen v. Brown for secondary service connection on the basis of the aggravation of a nonservice-connected disorder by a service-connected disability. See 71 Fed. Reg. 52744 (2006). The amendment sets forth language requiring that a baseline level of severity of the nonservice-connected disease or injury must be established by medical evidence created before the onset of aggravation. If a veteran was exposed to an herbicide agent during active military, naval, or air service, certain diseases are presumed to be service connected if the requirements of 38 C.F.R. § 3.307(a)(6) are met, even though there is no record of the disease during service, provided that the rebuttable presumption provisions of 38 C.F.R. § 3.307(d) are also satisfied. 38 U.S.C.A. § 1116(a) (West 2002 & Supp. 2011); 38 C.F.R. § 3.309(e). In this context, the term "herbicide agent" is defined as a chemical in an herbicide used in support of the United States and allied military operations in the Republic of Vietnam during the period beginning on January 9, 1962 and ending on May 7, 1975, specifically: 2,4-D; 2,4,5-T and its contaminant TCDD; cacodylic acid; and picloram. 38 C.F.R. § 3.307(a)(6)(i). Regardless of whether a claimed disability is recognized under 38 U.S.C.A. § 1116, pertaining to herbicide agent exposure presumptive diseases, a veteran is not precluded from presenting evidence that a claimed disability was due to or the result of herbicide exposure. Combee v. Brown, 34 F.3d 1039, 1044-45 (Fed. Cir. 1994); McCartt v. West, 12 Vet. App. 164, 167 (1999). 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). Myoclonus Initially, the Board notes that post-service treatment records reflect a diagnosis of myoclonus. In July 2005, October 2005, and November 2005, private physicians diagnosed the Veteran with generalized myoclonus. Additionally, a diagnosis of myoclonus was provided by a VA examiner in February 2010. Therefore, the evidence establishes the existence of the claimed disability. The Veteran's service treatment records do not reference treatment for any muscle complaints or contain a diagnosis of myoclonus. Upon discharge from his first period of service, clinical evaluation was normal for the Veteran's upper extremities, lower extremities, and spine. There were no neurological abnormalities noted on the September 1967 report of medical examination. The Veteran denied having or had in the past any bone, joint, or other deformity on his September 1967 report of medical history. Similarly, clinical evaluation for his upper extremities, lower extremities, and spine were normal with no neurological abnormalities noted, as reflected on the November 1970 expiration of term of service (ETS) report of medical examination. The Veteran's service personnel records document that he served in the Republic of Vietnam from September 1966 to September 1967. Because there is no affirmative evidence to the contrary, the Board presumes that he was exposed to herbicide agents such as Agent Orange. See 38 C.F.R. § 3.307(a)(6)(iii). Although the Veteran was exposed to herbicide agents, myoclonus is not one of the diseases listed as a disease associated with exposure to herbicide agents. See 38 C.F.R. § 3.309(e). Consequently, service connection is not warranted for myoclonus under the provisions of presumptive service connection pertaining to exposure to herbicide agents. See 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309. Other than exposure to Agent Orange, the Veteran has not identified any injury, disease, or event that occurred during his military service to which his myoclonus could possibly be attributed. Additionally, he has not identified any symptomatology that he may have experienced during service or continually since service. Instead, the Veteran concedes that he was not diagnosed with myoclonus until many years after service (in 2005). Specifically, the Veteran testified at the September 2009 Board hearing that his myoclonus began in 2005 after he experienced an episode of jerking with his feet jumping in the air while watching television. See the Board hearing transcript, page 3. He admitted that while he was discharged from service in 1970, he did not experience any symptoms associated with his myoclonus until 2005, and began to seek treatment shortly after his first episode. In support of his claim, the Veteran submitted a private medical statement from C.J., M.D., dated November 2005. Dr. C.J. noted that the Veteran was evaluated in August 2005 for myoclonus and also noted the Veteran's exposure to herbicides between 1966 and 1970 while stationed in Vietnam. Dr. C.J. stated that there is a "possible relationship between exposure to [a]gent [o]range and myoclonus as [there] [is] no other reasonable explanation." As the November 2005 private medical opinion provided a possible etiology regarding the Veteran's myoclonus, the Board determined that a VA examination was warranted to address the question of the possible relationship between the Veteran's myoclonus and his military service. See the December 2009 Board remand. According to a February 2010 VA examination report, a VA examiner diagnosed the Veteran with massive myoclonus that occurs primarily when at rest and is suppressed by activity. The February 2010 VA examiner concluded that based upon the reported history by the Veteran and a review of post-service VA treatment records, it is unlikely that the present delayed onset myoclonus is related to toxin exposure during active duty. He explained that while myoclonus has been reported as an acute or subacute effect of a wide range of toxin exposures, including herbicides, there is no peer reviewed article that describes a delayed onset, in this case approximately 33 years, as a complication of any toxin. In a May 2011 VA addendum opinion, the examiner again reiterated that with the long delay onset of symptoms, it is less likely than not, that anything occurring during military service was responsible for the current mycocolonus. The Board also notes that a second VA examiner physically examined the Veteran, reviewed the claims file, and agreed with the February 2010 VA examiner's conclusion. The VA physician indicated that the Veteran's myoclonus is not due to any service-related exposure because of the large delay of time between the onset of symptoms and any possible exposure that may have occurred in service. Since the first February 2010 VA examiner did not have access to the claims file in rendering his February 2010 opinion and May 2011 addendum opinion, and the second February 2010 VA examiner subsequently relied on the first examiner's assertions, the Board requested a VHA medical expert opinion to address the matter in June 2012. In July 2012, H.G., M.D., authored such an opinion. Dr. H.G. reviewed the evidence in the claims file, including the February 2010 VA opinions, the May 2011 VA addendum opinion, and the November 2005 private medical opinion. He explained that toxic exposures most typically produce their effects close to the time of the maximum exposure. In this case, the Veteran's exposure to toxins (herbicides) was between 1965 and 1970; however, the Veteran did not experience symptoms until 2003, approximately 33 years since the end of the exposure. Dr. H.G. stated that there are no reported cases in medical literature noting a 33-year delay between exposure to any toxin and myoclonus. Dr. H.G. acknowledged Dr. C.J.'s assertion that it is possible to have an association between the Veteran's exposure to herbicides in service and myoclonus, but explained that to indicate that herbicide exposure is a likely factor in the development of myoclonus is not supported by the typical time course of the disease after such toxin exposure. More importantly, he stated that just because there is no other explanation does not mean that the in-service exposure to herbicides should be the sole reason. Dr. H.G. opined that it is less likely than not that the Veteran's myoclonus had its clinical onset during active service or is related to any in service disease, injury, or herbicide exposure. In consideration of the evidence of record, the Board finds that the Veteran's myoclonus is not related to his active service, to include as due to herbicide exposure. The Board acknowledges the November 2005 private medical opinion, however, in weighing the probative value of such opinion, the Board finds that it is less probative than the probative February 2010 and May 2011 VA opinions and the highly probative July 2012 VHA opinion. As previously mentioned, Dr. C.J. concluded in November 2005 that there is a "possible relationship" between the Veteran's in-service herbicide exposure and his myoclonus. This implies that there could be a relationship between the two, but does not directly express that the Veteran's current myoclonus is attributable to his military service. The Court has held on numerous occasions that speculation is not legally sufficient to establish service connection. See Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992); Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992). An award of service connection must be based on reliable competent medical evidence and conjectural or speculative opinions as to some remote possibility of such relationship are insufficient. See 38 C.F.R. § 3.102 (2012); see also Morris v. West, 13 Vet. App. 94, 97 (1999) (diagnosis that appellant was "possibly" suffering from schizophrenia deemed speculative); Bloom v. West, 12 Vet. App. 185, 186-87 (1999) (treating physician's opinion that veteran's time as a prisoner of war "could" have precipitated the initial development of his lung condition found too speculative to be sufficient medical nexus evidence); Davis v. West, 13 Vet. App. 178, 185 (1999) (any medical nexus between in-service radiation exposure and fatal lung cancer years later was speculative at best, even where one physician opined that it was probable that lung cancer was related to service radiation exposure). Furthermore, while the February 2010 VA examiner did not have access to the Veteran's claims file in rendering his opinions, the two February 2010 VA opinions and the May 2011 VA addendum opinion are considered competent and probative medical evidence because they are factually accurate and supported by an adequate rationale, as the VA physicians were informed of the pertinent evidenced, namely the Veteran's exposure to herbicides in service. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that an opinion based upon an inaccurate factual premise has no probative value). The Board also finds the medical opinion from the July 2012 VHA examiner to be competent and probative medical evidence because it is based on a factually accurate history, including from a review of the claims file, and on the relevant evidence in this case, and the opinion is fully articulated and is supported by sound reasoning. Therefore, there is no probative medical evidence suggesting a link between the Veteran's period of service and his current diagnosis of myoclonus. The Board recognizes the sincerity of the arguments advanced by the Veteran that his myoclonus is caused by his military service. However, the resolution of issues that involve medical knowledge, such as the diagnosis of a disability and the determination of medical etiology, requires professional evidence. See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). It is true that the Veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). See also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). However, myoclonus requires specialized training for a determination as to diagnosis and causation, and is therefore not susceptible of lay opinions on etiology. Thus, because of the medical complexity of the matter, the Veteran simply is not competent to render such an opinion or attempt to present lay assertions to establish a nexus between his current diagnosis and service. For the reasons stated above, the Board finds that a preponderance of the evidence is against the claim of service connection for myoclonus, to include as due to herbicide exposure, and there is no doubt to be resolved. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Bilateral Foot Skin Disorder The Veteran contends that his bilateral foot skin disorder is related to his active military service. Specifically, at the September 2009 Board hearing, the Veteran testified that he began having problems with his feet in service after noticing them being wet all the time. Since that time, he has endured boils, rashes, swelling, and lesions on his feet. The Veteran asserts that his bilateral foot skin disorder is due to in-service herbicide exposure, or in the alternative, due to his service-connected diabetes mellitus, type II. At the outset, while it has been determined that the Veteran served in Vietnam during the Vietnam Era, and is presumed to have been exposed to herbicide agents during service, a bilateral foot skin disorder, namely bilateral dermatitis and eczema, is not among the diseases listed under 38 C.F.R. § 3.309(e), for which presumptive service connection based on herbicide exposure is available. Therefore, there is no basis for a presumptive grant of service connection for a bilateral foot skin disorder. Notwithstanding the inapplicability of the Agent Orange presumptive service connection regulations, the Board is obligated to fully consider the Veteran's service connection claim on a direct basis. See Combee, 34 F.3d at 1043-1044. Service treatment records reflect complaints and treatment for rashes on his penis and left ear, but no complaints, treatment, or a diagnosis of a bilateral foot skin disorder. See service treatment records dated May 1970 and September 1970. Upon discharge from service, clinical evaluation of the Veteran's feet were normal, as reflected on the September 1967 and November 1970 reports of medical examination. Additionally, the Veteran denied having any foot trouble or skin diseases on his September 1967 report of medical history at separation. Post service treatment records reflect treatment and complaints for a bilateral foot skin disorder. In his formal application for compensation benefits dated December 2004, the Veteran reported having skin rashes since 1978 due to his service in Vietnam. In a September 2002 private medical report, the Veteran denied having any history of skin rashes, pruritus, or psoriasis. Upon physical examination testing, the private physician noted that the Veteran's skin was warm and dry with no rashes, lesions, or discoloration. In January 2004, the Veteran reported to his local VA outpatient treatment facility. The Veteran reported a history of recurring skin rashes since 1984 or 1985. He explained that the rashes are a "raised hive type lesion" that burns, itches, and forms a blister type lesion that stays under the skin. Physical examination testing revealed warm skin with no rashes or lesions. At a May 2005 VA Agent Orange examination, the Veteran reported skin rashes on his feet that have been treated with Benadryl. In December 2007 and May 2009, the Veteran displayed normal feet in appearance at VA diabetic foot examinations. In February 2010, a VA examiner diagnosed the Veteran with bilateral foot dermatitis and eczema Based upon the evidence in the claims file, the first objective complaints and showing of a bilateral foot skin disorder was demonstrated in the January 2004 VA outpatient treatment note and February 2010 VA examination report, many years after service. The Board acknowledges that the Veteran has contended, in essence, that his skin problems associated with his feet have existed since his military service. The Board has considered the provisions of 38 C.F.R. § 3.303(b), relating to chronicity and continuity of symptomatology. However, the evidence weighs against the Veteran's claim in this regard. The weight of the evidence does not show chronic bilateral foot skin disorder during service or immediately thereafter. See Voerth v. West, 13 Vet. App. 117, 120-21 (1999) (there must be medical evidence on file demonstrating a relationship between the Veteran's current disability and the claimed continuous symptomatology, unless such a relationship is one as to which a lay person's observations is competent). The Veteran's service treatment records show that he complained of rashes in 1970, but the rashes complained of were located on the left ear and penis. In addition, the post service treatment reports do not show any complaints of foot problems until 2004 and a diagnosis of the bilateral foot skin disorder was not made until February 2010. In addition, the gap between separation from service and reported symptoms related to his bilateral foot skin disorder can be considered, along with other factors concerning the Veteran's health and medical treatment during and after military service. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board acknowledges that the Veteran is competent to give evidence about what he has experienced; for example, he is competent to discuss his current symptomatology and other experienced symptoms. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). Furthermore, lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). It is acknowledged that the Veteran has asserted throughout this appeal that he incurred his current bilateral foot skin disorder while serving in Vietnam. He has contended that the bilateral foot skin disorder has never resolved and has since endured rashes, swelling, boils and lesions of the feet. Thus, his statements can be construed as alleging a continuity of residuals of a bilateral foot skin disorder since his military service. However, the Board finds that the allegations of continuity are not credible. While the Veteran was treated for rashes on the left ear and penis in service, there were no reported treatment for rashes on the feet, no bilateral foot skin disorder was noted upon separation, and no post service reference was made to a bilateral foot skin disorder until 2004. Additionally, the Veteran reported having skin rashes since 1978, several years after discharge from service, in a December 2004 application for formal benefits, and during a January 2004 VA outpatient treatment visit, he reported a history of skin rashes since 1984 or 1985. These inconsistencies in the record weigh against the Veteran's credibility as to the assertion of continuity of symptomatology since service. See Madden v. Gober, 125 F.3d 1477, 1481 (Board entitled to discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence); Caluza v. Brown, 7 Vet. App. 498, 512 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (upholding Board's finding that a veteran was not credible because lay evidence about a wound in service was internally inconsistent with other lay statements that he had not received any wounds in service). As such, continuity of symptomatology has not been established, and the Veteran's testimony regarding his disability, standing alone, are not sufficiently credible to provide probative information. The Board further finds that the weight of the evidence demonstrates that the Veteran's current bilateral foot skin disorder (bilateral foot dermatitis and eczema) is not related to active service. In February 2010, the Veteran was afforded a VA examination to determine the etiology of the bilateral foot skin disorder. The Veteran reported a history of skin rashes since 1966, while stationed in Vietnam. He complained of constant dryness, peeling, itching, and redness of the skin. After physical examination testing, the VA examiner diagnosed the Veteran with bilateral foot dermatitis/eczema. After review of the claims file and physical examination findings, the VA examiner opined that it is less likely as not that the Veteran's bilateral foot skin disorder is caused by or a result of herbicide exposure in service. The VA examiner explained that there are conflicting reports as to the onset of the bilateral foot skin disorder, as well as no evidence of in-service herbicide exposure. The VA examiner referenced the Veteran's assertion that the skin disorder of the feet began in 1966, while stationed in Vietnam at this examination, but also noted the Veteran's statement regarding onset approximately in 1984 or 1985 in a January 2005 VA outpatient treatment note. Additionally, the VA examiner stated that service treatment records noted no skin disorders. Thus, the examiner concluded that based on the stated contradictions, he was unable to conclude that the bilateral foot skin disorder began in service or as a result of in-service herbicide exposure, but rather it was more likely that the Veteran's bilateral foot skin disorder was unrelated to any exposure while in service. In a May 2011 VA addendum opinion, the examiner stated that the bilateral foot skin disorder did not have its onset during service, as the Veteran demonstrated normal skin in 1967, and it was documented that it began in approximately 1984 or 1985. He concluded that the bilateral foot skin disorder is not due to an in-service disease, event, or injury and it is also not due to the Veteran's service-connected diabetes mellitus, type II, as it was not diagnosed until 2004. In June 2012, the Board requested a VHA opinion to determine the etiology of the Veteran's bilateral foot skin disorder. An opinion was obtained from P.A., M.D. After an extensive review of the Veteran's claims file, Dr. P.A. acknowledged the Veteran's assertions of a bilateral skin disorder since 1966. However, he explained that this could not be confirmed with his service treatment records. Additionally, he noted that the Veteran's symptomatology of the bilateral foot skin disorder does not suggest the presence of any of the classic skin disorders related to Agent Orange, such as chloracne, porphyria cutanea tarda, or malignant melanoma. Dr. P.A. concluded that the Veteran's claims of a bilateral foot skin disorder originate from this century, and there is nothing in the record to suggest that the bilateral foot skin disorder occurred prior to this time other than the Veteran's own assertions. After review of the evidence, the Board finds that the February 2010 and May 2011 VA opinions are not as probative as the VHA opinion. As mentioned, the February 2010 VA examiner determined that the Veteran's bilateral foot skin disorder is not related to his active service, as well as due to herbicide exposure. The examiner specifically stated that the Veteran's exposure to herbicides had not been documented. The Board notes that this is an inaccurate statement as service personnel records confirm the Veteran's presence in Vietnam and as such, the Board presumes that he was exposed to herbicide agents such as Agent Orange. See 38 C.F.R. § 3.307(a)(6)(iii). The Board points out that, as a medical opinion can be no better than the facts alleged by the Veteran, an opinion based on an inaccurate factual premise has no probative value. See Reonal v. Brown, 5 Vet. App. 460, 461 (1993); Swann v. Brown, 5 Vet. App. 229, 233 (1993); Black v. Brown, 5 Vet. App. 179, 180 (1993). On the contrary, the Board finds the medical opinion from the July 2012 VHA examiner to be competent and probative medical evidence because it is based on a factually accurate history, including from a review of the claims file, and on the relevant evidence in this case, and the opinion is fully articulated and is supported by sound reasoning. Therefore, there is no probative medical evidence suggesting a link between the Veteran's period of service and his bilateral foot skin disorder, to include as due to herbicide exposure. The Board notes that the Veteran has also asserted that his bilateral foot skin disorder is caused by his service-connected diabetes mellitus, type II. As noted, the Veteran has been diagnosed with bilateral dermatitis/eczema and in addition, service connection is in effect for diabetes mellitus, type II. Thus, the remaining question is whether or not the Veteran's bilateral foot skin disorder is caused by the Veteran's service-connected diabetes mellitus, type II. As previously mentioned, the May 2011 VA addendum opinion concluded that the Veteran's bilateral dermatitis/eczema was not due to his service-connected diabetes mellitus, type II, because it was diagnosed later in 2004. However, because the May 2011 VA addendum opinion failed to explain whether the Veteran's bilateral dermatitis/eczema was aggravated by the service-connected diabetes mellitus, type II, a VHA was requested. In the VHA opinion, Dr. P.A. reviewed the claims file, noting the onset of diabetes in 2004 and the first signs of a bilateral foot skin disorder in 2004 or 2005. He concluded that based upon the evidence, the Veteran's bilateral foot skin disorder developed after the Veteran was diagnosed with diabetes mellitus, type II. Dr. P.A. explained that even if the Veteran's bilateral foot skin disorder existed in service, his service-connected diabetes mellitus, type II, did not make the bilateral foot skin disorder worse. This opinion is supported by VA treatment records dated as recently as December 2007 and May 2009, which noted that the Veteran displayed normal feet at VA diabetic foot examinations. Similar to the other theory of entitlement, the Veteran has not provided or pointed to any evidence that his service-connected diabetes mellitus, type II, aggravated his bilateral foot skin disorder other than his own assertions throughout the appeal. In consideration of the competent and probative medical opinion evidence, the Board finds that the Veteran does not have bilateral dermatitis and eczema that was caused or aggravated by service-connected diabetes mellitus, type II. In view of this finding, the Board concludes that service connection is not warranted for a bilateral foot skin disorder on a secondary basis. See 38 U.S.C.A. § 1110; 38 C.F.R. § 3.310. The Board recognizes the sincerity of the arguments advanced by the Veteran that his bilateral foot skin disorder is caused by his military service. However, the resolution of issues that involve medical knowledge, such as the diagnosis of a disability and the determination of medical etiology, requires professional evidence. See Espiritu v. Derwinski, 2 Vet. App. 492, 495 (1992). It is true that the Veteran's lay statements may be competent to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C.A. § 1153(a); 38 C.F.R. §§ 3.303(a), 3.159(a); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). See also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). However, bilateral foot skin disorder (bilateral dermatitis/eczema) requires specialized training for a determination as to diagnosis and causation, and is therefore not susceptible of lay opinions on etiology. Thus, because of the medical complexity of the matter, the Veteran simply is not competent to render such an opinion or attempt to present lay assertions to establish a nexus between his current diagnosis and service. For the reasons stated above, the Board finds that a preponderance of the evidence is against the claim of service connection for a bilateral foot skin disorder (i.e., rashes, swelling, and dislocation), including as due to herbicide exposure and as secondary to service-connected diabetes mellitus, type II, and there is no doubt to be resolved. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Service connection for myoclonus, including as due to herbicide exposure, is denied. Service connection for a bilateral foot disorder (i.e., rashes, swelling, and dislocation), including as due to herbicide exposure and as secondary to service-connected diabetes mellitus, type II, is denied. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs