Citation Nr: 1305174 Decision Date: 02/12/13 Archive Date: 02/21/13 DOCKET NO. 96-28 831 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for bilateral pes planus (claimed as a bilateral foot disability). 3. Entitlement to service connection for a bilateral knee disability. 4. Entitlement to service connection for a bilateral ankle disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from March 1969 to January 1973. This case comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. In May 1996, the RO declined to reopen the Veteran's claim for service connection for a low back disability. In June 1996, the Veteran filed a Notice of Disagreement. The RO furnished the Veteran a Statement of the Case in October 1996, and the Veteran filed a Substantive Appeal (VA Form 9) later in October 1996. In August 2005, the RO denied entitlement to service connection for bilateral pes planus, a bilateral knee disability, and a bilateral ankle disability. In November 2005, the Veteran filed a Notice of Disagreement. The RO furnished the Veteran a Statement of the Case in May 2006, and the Veteran filed a Substantive Appeal (VA Form 9) in July 2006. The Board remanded the Veteran's claim to reopen service connection for a low back disability in December 2005 and December 2008. In February 2012, the Board reopened the Veteran's claim for service connection for a low back disability and remanded it for additional development, along with his claims for service connection for bilateral pes planus, a bilateral knee disability, and a bilateral ankle disability. The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. The issue of entitlement to service connection for a bilateral ankle disability is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. A chronic low back disability was not shown in service or for many years thereafter, and the most probative evidence fails to link the Veteran's current low back disability to service. 2. Medical findings in service reveal that bilateral pes planus was noted on the 1969 induction examination report and thus was present prior to service; however, the most probative evidence of record clearly and unmistakably establishes that such disability was not permanent worsening beyond normal progression as a result of the Veteran's active service. 3. A chronic bilateral knee disability was not shown in service or for many years thereafter, and the most probative evidence fails to link the Veteran's current bilateral knee disability to service. CONCLUSIONS OF LAW 1. A low back disability was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1112, 1153, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). 2. Bilateral pes planus was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1112, 1153, 5107 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.303, 3.304(b), 3.306 (2012). 3. A bilateral knee disability was not incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1112, 1153, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act The Veterans Claims Assistance Act (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) redefined VA's duty to assist the appellant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). The notice requirements of the VCAA require VA to notify the Veteran of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2012). The requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). VCAA notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO). Id; see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). However, insufficiency in the timing or content of VCAA notice is harmless if the errors are not prejudicial to the claimant. Conway v. Principi, 353 F.3d 1369, 1374 (Fed. Cir. 2004) (VCAA notice errors are reviewed under a prejudicial error rule). Regarding the claims for service connection for bilateral pes planus and a bilateral knee disability, in an April 2005 letter, issued prior to the rating decision on appeal, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. A May 2006 Statement of the Case informed the Veteran of the evidence needed to establish a disability rating and effective date for the claims on appeal. With respect to the claim for service connection for a low back disability, in a February 2004 letter issued after the decision on appeal, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, as well as what information and evidence must be submitted by the Veteran and what information and evidence will be obtained by VA. A February 2009 letter informed the Veteran of the evidence needed to establish a disability rating and effective date for the claim on appeal. Although the February 2004, May 2006, and February 2009 notifications were issued after the decisions on appeal, the Veteran's case was subsequently readjudicated as evidenced by Supplemental Statements of the Case dated in February 2007, May 2011, and November 2012, and he had the opportunity to submit additional argument and evidence. Therefore, the content timing error did not affect the essential fairness of the adjudication of the claims. Mayfield v. Nicholson, 499 F.3d 1317 (Fed. Cir. 2007) (Timing error cured by adequate VCAA notice and subsequent readjudication without resorting to prejudicial error analysis.). The record also reflects that VA has made reasonable efforts to obtain relevant records adequately identified by the appellant. Specifically, the information and evidence that have been associated with the claims file include the service treatment records, VA medical records, VA examination reports, and the Veteran's statements. The Board notes that actions requested in the prior remands have been undertaken. Instructions pertinent to the claims being decided included obtaining updated VA treatment records (including treatment for a low back disorder in 1975), sending the Veteran notice that was compliant with Dingess/Hartman v. Nicholson for his low back disability, and scheduling the Veteran for VA examinations to determine the etiologies of his low back, pes planus, and knee disabilities. In response, the RO/AMC obtained all available current VA treatment records from the VA Medical Center in Dallas, Texas. The RO/AMC also sent a February 2009 letter that complied with the notice requirements in Dingess/Hartman v. Nicholson. The RO/AMC also scheduled the Veteran for May 2012 VA examinations and obtained July 2012 VA addendum opinions for the examinations. Regarding the VA treatment for a low back disorder in 1975, the RO/AMC attempted to obtain these records, but such records were not available. The RO made a formal finding regarding the unavailability of the 1975 VA treatment records in April 2010. The Veteran was informed of this in an April 2010 letter, and was requested to submit any additional evidence in his possession. Accordingly, the Board finds that there has been substantial compliance with the prior remand instructions and no further action is necessary. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)). As discussed above, the VCAA provisions have been considered and complied with. The appellant was notified and aware of the evidence needed to substantiate these claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. The Veteran has been an active participant in the claims process by reporting for VA examinations, responding to notices, and submitting evidence and argument. Thus, the Veteran has been provided with a meaningful opportunity to participate in the claims process and has done so. Any error in the sequence of events or content of the notice is not shown to have affected the essential fairness of the adjudication or to cause injury to the claimant. Therefore, any such error is harmless and does not prohibit consideration of these matters on the merits. See Conway, supra; Dingess, supra; see also ATD Corp. v. Lydall, Inc., 159 F.3d 534, 549 (Fed. Cir. 1998). Analysis The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the appellant or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Low Back Disability The Veteran contends that he sprained his low back in 1969 during service when he fell backwards after handing a document to an officer who was hovering in a helicopter. He alleges that he subsequently sprained his back on several more occasions during service when he fell on hills, and that he has experienced low back pain since service. Service treatment records show that in a March 28, 1972 treatment record, the Veteran complained of pain in the right flank for 5 days and was diagnosed with muscle strain. A March 29, 1972 treatment record indicated that the Veteran underwent a recheck for his low back pain. He reported that his back pain bothered him when he was stooping or reaching and also in the morning after sleeping. He was again diagnosed with muscle strain and received heat treatment. In an April 1972 treatment record, the Veteran was again seen for low back pain. On separation examination in December 1972, the Veteran made no complaints regarding his back, and his spine was found to have no abnormalities. The post-service medical evidence of record shows that on VA examination in May 1984, the Veteran reported a history of an onset of low back problems in 1971 or 1972. He complained of intermittent paralysis of the back which would last for 10 or 15 minutes and render him unable to get out of bed. An x-ray of the lumbar spine revealed bilateral spondylolysis of L5 with a Grade I spondylolisthesis. The examiner noted that the examination of the back was essentially normal and diagnosed the Veteran with history of intermittent paralysis of the back and spondylolisthesis of L5. A September 1995 VA medical report reflected treatment for chronic lumbar strain. VA medical records dated from May 2003 to January 2005 show that the Veteran received intermittent treatment for low back pain. A September 2003 x-ray of the lumbar spine indicated that there was mild degenerative joint disease. On VA examination in December 2006 to assess employability, the Veteran stated that his low back problem had originated during his service in Vietnam and that it had bothered him ever since. He was diagnosed with a low back pain problem with spondylolysis and spondylolisthesis. An x-ray of the lumbar spine revealed Grade II spondylolisthesis of L5-S1. At a May 2012 VA examination, the Veteran reported that he sprained his low back in 1969 during his service in Vietnam when he fell back after handing a document to an officer hovering in a helicopter above a rice paddy. He maintained that this was treated conservatively on an outpatient basis in the field and did not include physical therapy. The Veteran indicated that he subsequently sprained his back on several more occasions, usually in falls on hills and that these injuries were also treated conservatively on an outpatient basis in the field. He denied any hospitalization or invasive treatment of his conditions. He complained of experiencing chronic, intermittent, and progressively worsening mechanical low back pain ever since service. He reported currently suffering from daily severe mechanical low back pain, intermittent severe bilateral sciatica, and daily bilateral leg paresthesias, dysthesias, and numbness. After examination of the spine, the Veteran was diagnosed with chronic, mild acquired L5 spondylolisthesis and chronic, mild lumbar spondylosis. However, the Veteran's claims file was unavailable for review, and therefore the examiner could not provide an etiology opinion regarding the low back disability without resorting to mere speculation. In a July 2012 VA addendum opinion, the May 2012 VA examiner reviewed the Veteran's entire claims file and opined that the Veteran's low back disability was less likely than not incurred in or caused by his period of service. The examiner found that it was more likely than not that the Veteran's current lumbar spine disability was due to chronic degenerative changes associated with aging. He based his opinion on the March 1972 and April 1972 in-service treatment for only acute back muscle strain and the December 1972 separation examination documenting a normal spine examination. The Board reiterates that although the Veteran was treated for low back muscle strain and pain 3 times during service, at his December 1972 separation examination, he was not diagnosed with any lumbar spine disability. In addition, arthritis of the lumbar spine was not shown to a compensable degree within one year following the Veteran's discharge from service. Moreover, the Board notes that at no time did any of the Veteran's treating providers find that his low back disability was due to his period of service. The May 2012 VA examiner reviewed the claims file in July 2012, interviewed and examined the Veteran, and provided adequate reasoning and bases for the opinion that it was less likely than not that the Veteran's low back disability was related to his period of service. The May 2012 VA examiner noted that the Veteran was only treated for acute back muscle strain in service and that his separation examination was normal for the lumbar spine. He also explained that the Veteran's low back condition was more likely due to chronic degenerative changes associated with aging. For these reasons, the opinion by the May 2012 VA examiner is afforded great probative value. The only opinion supporting the Veteran's claim consists of his own statements. It is now well established that lay persons without medical training, such as the Veteran, are not competent to provide medical opinions on matters requiring medical expertise, such as the diagnosis or etiology of musculoskeletal disabilities. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, joint pain can have many causes and requires medical testing to diagnose and medical expertise to determine the etiology of the pain. Moreover, whether the symptoms the Veteran reportedly experienced in service or following service are in any way related to his current low back disorder is a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's opinions regarding the onset and etiology of his current low back disability are not competent medical evidence. For the reasons set forth above, the Board finds the July 2012 opinion by the May 2012 VA examiner (which was accompanied by detailed supporting rationale) to be of greater probative value than the Veteran's lay contentions regarding the etiology of his low back disability. In sum, the Board finds that the competent and probative evidence indicates that a chronic low back disability was not shown in service, and the most probative evidence fails to link the Veteran's current low back disability to service. Accordingly, service connection for a low back disability is not warranted. See 38 C.F.R. § 3.303 (2012). In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Bilateral Pes Planus The Veteran contends that he was first made aware of his pes planus on his 1969 induction examination. He alleges that he first began experiencing bilateral heel pain in the 1990's. A veteran will be considered to have been in sound condition when examined and accepted for service, except as to disorders noted on entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service and was not aggravated by service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). A preexisting injury or disease will be considered to have been aggravated by service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. Whether a preexisting disorder underwent an increase in severity during service is determined based on evidence of the manifestations of the disorder before, during, and after service. 38 C.F.R. § 3.306. For a disorder to be considered aggravated in service, there must be worsening of the underlying condition, not just temporary or intermittent flare-ups of the symptoms of the condition. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Evidence of a veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). In order to support a finding of aggravation, the evidence must establish that the underlying disability underwent an increase in severity; the occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a). On induction examination in March 1969, the Veteran was noted to have pes planus that was nonsymptomatic, nondisabling (NSND). Service treatment records are negative for any complaints or treatment for bilateral pes planus. At his December 1972 separation examination, the Veteran made no complaints regarding his feet, and his feet were found to have no abnormalities. The first post-service medical evidence of record relating to bilateral pes planus is a November 1994 VA medical report in which the Veteran complained of bilateral foot pain in the morning. A February 2004 VA medical report indicates that the Veteran fractured his left fifth toe after hitting it against a door. An x-ray of the left foot revealed a left fifth toe fracture but was otherwise unremarkable. A March 2005 VA medical report shows that the Veteran fractured his left fourth toe after hitting it against his couch. VA medical records dated from March 2005 to July 2005 reflect intermittent treatment for the Veteran's left fourth toe fracture, including an orthopedic shoe request and the use of a walker. In an October 2006 VA medical report, the Veteran reported pain in the middle of his left foot after returning from a fishing trip and being up and down a slope for 3 days. He was diagnosed with left foot pain, rule out fracture, and it was noted that he had likely sprained his left foot. On VA examination in December 2006 to assess employability, the Veteran stated that he had had flat feet since he was in the military. He was diagnosed with bilateral flat foot of moderate extent, and his feet were noted to be symptomatic. An October 2006 x-ray of the left foot revealed no evidence of fracture, dislocation, arthritic change, or radiopaque foreign body. There was evidence of calcaneal spur. At a May 2012 VA examination, the Veteran reported that he first became aware that he had flat feet during his 1969 induction examination. He denied any symptoms or treatment for this condition while on active duty. He stated that he first began experiencing chronic, intermittent, and progressively worsening bilateral heel pain in the early 1990's. He maintained that this had been treated conservatively on an outpatient basis only. He reported being dispensed arch support orthotics. He denied receiving any physical therapy, invasive treatment, or hospitalization for his condition. He complained of currently suffering from daily moderate to severe bilateral plantar heel pain with any prolonged walking or standing. After examination, the Veteran was diagnosed with flat foot, hammer toes, and plantar fasciitis. However, the Veteran's claims file was unavailable for review, and therefore the examiner could not provide an etiology opinion regarding the bilateral knee disability without resorting to mere speculation. In a July 2012 VA addendum opinion, the May 2012 VA examiner reviewed the Veteran's entire claims file and opined that the Veteran's bilateral pes planus, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by any incidents of service. The examiner explained that the 63 year old Veteran had radiographic evidence of only mild pes planus, and that his current pes planus was more likely than not due to chronic degenerative changes associated with aging. The examiner pointed out that the March 1969 induction examination found the Veteran's pes planus to be NSND and that his feet were found to be normal on separation examination in December 1972. The examiner also noted that the May 2012 x-rays of the Veteran's feet revealed bilateral plantar calcaneal spurs, but the bones and soft tissues were otherwise normal in appearance. Similarly, the May 2012 x-rays of the Veteran's ankles indicated the presence of pes planus and bilateral plantar calcaneal spurs, but there were no bone, joint, or soft tissue abnormalities. The initial determination is whether bilateral pes planus was present prior to service. In Crowe v. Brown, 7 Vet. App. 238 (1994), the Court indicated that the presumption of soundness attaches only where there has been an induction medical examination, and where a disability for which service connection is sought was not detected at the time of such examination. The Court added that the regulation provides expressly that the term "noted" denotes only such conditions as are recorded in examination reports, and that history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions. 38 C.F.R. § 3.304(b)(1) (2012). In this case, the medical evidence clearly and unmistakably shows that pes planus was noted in the Veteran's March 1969 entrance examination report. The Board concludes, accordingly, that the presumption of soundness at entrance does not attach. Instead, it must now be determined whether the preexisting disability was aggravated by service. Under 38 U.S.C.A. § 1153, aggravation will be established by an increase in disability during service, absent a specific finding that the increase was due to the natural progress of the disease. 38 C.F.R. § 3.306(a). This standard is further explained in 38 C.F.R. § 3.306(b), which provides that clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. This includes medical facts and principles which may be considered to determine whether the increase is due to the natural progress of the condition. Id. As will be discussed below, the most probative evidence of record clearly and unmistakably establishes that the Veteran's preexisting bilateral pes planus underwent no permanent worsening beyond normal progression during his active service. The Board notes that at no time did any of the Veteran's treating providers find that his bilateral pes planus was aggravated by his period of service. However, the May 2012 VA examiner reviewed the claims file in July 2012, interviewed and examined the Veteran, and provided adequate reasoning and bases for the opinion that the Veteran's preexisting bilateral pes planus was clearly and unmistakably not aggravated beyond its natural progression by any incidents of service. The May 2012 VA examiner explained that the Veteran had radiographic evidence of only mild pes planus, and that his current pes planus was more likely than not due to chronic degenerative changes associated with aging. The examiner also noted the normal feet examinations at the December 1972 separation examination, as well as the May 2012 x-rays of the feet and ankles that were negative for any abnormalities other than bilateral pes planus and calcaneal spurs. For these reasons, the opinion by the May 2012 VA examiner is afforded great probative value. The only opinion supporting the Veteran's claim consists of his own statements. It is now well established that lay persons without medical training, such as the Veteran, are not competent to provide medical opinions on matters requiring medical expertise, such as the diagnosis or etiology of musculoskeletal disabilities. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, joint pain can have many causes and requires medical testing to diagnose and medical expertise to determine the etiology of the pain. Moreover, whether the symptoms the Veteran reportedly experienced in service or following service are in any way related to his current pes planus is a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's opinion regarding the etiology of his current bilateral pes planus is not competent medical evidence. For the reasons set forth above, the Board finds the July 2012 opinion by the May 2012 VA examiner (which was accompanied by detailed supporting rationale) to be of greater probative value than the Veteran's lay contentions regarding the etiology of his bilateral pes planus. In sum, the Board determines that the presumption of aggravation under 38 U.S.C.A. § 1153 and 38 C.F.R. § 3.306(b) is rebutted by clear and unmiskable evidence demonstrating that the Veteran's preexisting pes planus did not undergo a permanent worsening beyond normal progression during his active service. Accordingly, service connection based on aggravation of the preexisting bilateral pes planus (claimed as a bilateral foot disability) is not warranted. Id. Bilateral Knee Disability The Veteran contends that he sustained a left tibia laceration during service when he tripped and fell against an object while he was carrying something. He alleges that he has experienced bilateral knee pain ever since service. Service treatment records show that in June 1972, the Veteran fell on a tree stump in the field and sustained a laceration over his left proximal tibia-fibula. X-rays were negative, and the Veteran was treated with dressing and a tetanus immunoprophylaxis. On separation examination in December 1972, the Veteran made no complaints regarding his knees, and his bilateral lower extremities were found to be within normal limits. Post-service VA medical records dated from January 2005 to January 2007 show that the Veteran received intermittent treatment for right knee pain. On VA examination in December 2006 to assess employability, the Veteran stated that he had experienced bilateral knee pain since the 1980's. He was diagnosed with bilateral arthritis of the knees. An x-ray of the knees revealed mild medial and lateral compartment narrowing, bilaterally. At a May 2012 VA examination, the Veteran reported that he had sustained a left tibia laceration in 1970 after he tripped and fell against an object as he was carrying something while in garrision during his service in Germany. He stated that this had been treated on an outpatient basis only with local suture wound repair. He complained that he developed chronic, intermittent, and progressively worsening mechanical left knee pain around 1971 or 1972 but denied any knee injuries. He also indicated that this had been treated on an outpatient basis only with no physical therapy. He denied any other invasive treatment or hospitalization for these conditions. The Veteran maintained that he subsequently developed right knee pain in the 1990's but denied any right knee injuries. He reported currently suffering from severe bilateral mechanical knee pain every day, bilateral knee effusion in the left knee more frequently than the right knee every 2 to 3 months, and bilateral knee instability once or twice a month. After examination, the Veteran was diagnosed with osteoarthritis of the bilateral knees. However, the Veteran's claims file was unavailable for review, and therefore the examiner could not provide an etiology opinion regarding the bilateral knee disability without resorting to mere speculation. In a July 2012 VA addendum opinion, the May 2012 VA examiner reviewed the Veteran's entire claims file and opined that the Veteran's bilateral knee disability was less likely than not incurred in or caused by his period of service. The examiner found that it was more likely than not that the Veteran's current bilateral knee disability was due to chronic degenerative changes associated with aging. He based his opinion on the June 1972 in-service left pretibial superficial laceration, pointing out that radiographic examinations of the tibia/fibula were within normal limits and treatment was only with application of dressing and tetanus immunoprophylaxis. The examiner also noted that the December 1972 separation examination documented normal bilateral lower extremities examinations. The Board reiterates that although the Veteran was treated once for a left tibia superficial laceration during service, at his December 1972 separation examination, he was not diagnosed with any bilateral knee disability. In addition, arthritis of the knees was not shown to a compensable degree within one year following the Veteran's discharge from service. Moreover, the Board notes that at no time did any of the Veteran's treating providers find that his bilateral knee disability was due to his period of service. The May 2012 VA examiner reviewed the claims file in July 2012, interviewed and examined the Veteran, and provided adequate reasoning and bases for the opinion that it was less likely than not that the Veteran's bilateral knee disability was related to his period of service. The May 2012 VA examiner noted that the Veteran was only treated for a superficial left tibia laceration in service and that his separation examination was normal for the bilateral lower extremities. He also explained that the Veteran's bilateral knee condition was more likely due to chronic degenerative changes associated with aging. For these reasons, the opinion by the May 2012 VA examiner is afforded great probative value. The only opinion supporting the Veteran's claim consists of his own statements. It is now well established that lay persons without medical training, such as the Veteran, are not competent to provide medical opinions on matters requiring medical expertise, such as the diagnosis or etiology of musculoskeletal disabilities. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, joint pain can have many causes and requires medical testing to diagnose and medical expertise to determine the etiology of the pain. Moreover, whether the symptoms the Veteran reportedly experienced in service or following service are in any way related to his current bilateral knee disorder is a matter that requires medical expertise to determine. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) ("Although the veteran is competent to testify to the pain he has experienced since his tour in the Persian Gulf, he is not competent to testify to the fact that what he experienced in service and since service is the same condition he is currently diagnosed with."). Thus, the Veteran's opinions regarding the onset and etiology of his current bilateral knee disability are not competent medical evidence. The Board notes that service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2012). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310 (2012); Allen v. Brown, 7 Vet. App. 439 (1995). Although the Veteran had not specifically asserted that his claimed bilateral knee disability was related to his bilateral pes planus, in a February 2012 remand, the Board found that the issue of secondary service connection had been reasonably raised by the record. However, the Board has determined in the above decision that service connection is not warranted for bilateral pes planus, and therefore service connection for a bilateral knee disability cannot be established on a secondary basis in relation to the Veteran's non-service-connected bilateral pes planus. For the reasons set forth above, the Board finds the July 2012 opinion by the May 2012 VA examiner (which was accompanied by detailed supporting rationale) to be of greater probative value than the Veteran's lay contentions regarding the etiology of his bilateral knee disability. In sum, the Board finds that the competent and probative evidence indicates that a chronic bilateral knee disability was not shown in service, and the most probative evidence fails to link the Veteran's current bilateral knee disability to service. Additionally, service connection has not been established for bilateral pes planus. Accordingly, service connection for a bilateral knee disability on either a direct or a secondary basis is not warranted. See 38 C.F.R. §§ 3.303, 3.310(a) (2012). In reaching the conclusion above, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. See 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Entitlement to service connection for a low back disability is denied. Entitlement to service connection for bilateral pes planus is denied. Entitlement to service connection for a bilateral knee disability is denied. REMAND Although the Board sincerely regrets the additional delay, after a review of the record, further development is required prior to adjudicating the Veteran's claim for service connection for a bilateral ankle disability. Pursuant to the Board's February 2012 remand, the Veteran underwent a VA examination in May 2012, in pertinent part, to determine whether he had any current bilateral ankle disability that was related to his period of active service. On VA examination in May 2012, the Veteran reported that he had sustained multiple mild bilateral ankle sprains during active service for which he did not seek medical attention. He indicated that he had experienced chronic intermittent bilateral ankle pain and swelling ever since discharge from service. He also denied any severe injuries requiring cast or other immobilization or limited weightbearing during or following service. He complained that he currently suffered from chronic bilateral ankle instability and intermittent bilateral ankle swelling with prolonged walking or standing. Upon examination, the examiner diagnosed the Veteran with chronic, moderate right ankle sprain. However, the Veteran's claims file was unavailable for review, and therefore the examiner could not provide an etiology opinion regarding the right ankle sprain without resorting to mere speculation. In a July 2012 VA addendum opinion, the May 2012 VA examiner reviewed the Veteran's entire claims file and opined that the Veteran's right ankle sprain was less likely than not incurred in or caused by his period of service. The examiner explained that on review of the Veteran's service treatment records, he was unable to identify any documentation of treatment for a right ankle sprain. He indicated that there was only a June 1972 documentation of a left pretibial superficial laceration that was treated with application of dressing and tetanus immunoprophylaxis. Radiographic examinations of the left tibia/fibula were noted to be within normal limits. The examiner also stated that the Veteran's December 1972 separation examination revealed normal bilateral lower extremities examinations. He concluded that he could not comment further without resorting to mere speculation. The May 2012 VA examiner provided an opinion that the Veteran's right ankle sprain was not related to his period of service and supported his opinion partly on the fact that there was no documentation of any treatment for a right ankle sprain in the Veteran's service treatment records. However, the Board notes that an October 1971 service treatment record reveals that the Veteran had twisted his right ankle the night before while playing football. He had full range of motion of the ankle. There was no swelling, but some tenderness was present. The diagnostic impression was that of a right ankle sprain, and the Veteran was treated with an Ace bandage. Therefore, the VA examiner's medical opinion was based on an inaccurate factual premise. Given that the May 2012 VA examiner based his opinion on an inaccurate factual premise, the claims file should be returned to the May 2012 examiner, if available, in order to obtain another opinion regarding any relationship between the Veteran's bilateral ankle disability and his military service. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. Return the claims file to the examiner who conducted the May 2012 VA examination and provided the July 2012 addendum opinion, if available. The examiner should once again review the claims file and provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that any current bilateral ankle disability arose during service or is otherwise related to any incident of service, including the October 1971 treatment for a right ankle sprain. The examiner should explain the medical basis for the conclusions reached. If the examiner determines that an examination of the Veteran is necessary to provide the requested opinion with rationale, then such examination should be scheduled. If the previous examiner is no longer available, then the requested opinion with rationale should be rendered by another qualified examiner. 2. After the development requested above as well as any additional development deemed necessary has been completed, the record should again be reviewed. If the benefits sought on appeal remain denied, then the Veteran and his representative should be furnished with a supplemental statement of the case and be given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs