Citation Nr: 1305753 Decision Date: 02/19/13 Archive Date: 02/27/13 DOCKET NO. 10-14 838 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for hypertension. 2. Entitlement to service connection for a back disorder. 3. Entitlement to service connection for a bilateral foot disorder. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from October 1974 to September 1976. These matters come before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision decided by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, and issued by the RO in North Little Rock, Arkansas, which denied the Veteran's claims for service connection for hypertension, a back condition and a bilateral foot condition. A review of the Virtual VA claims processing system reveals VA treatment records dated through February 2012, which were considered in the August 2012 supplemental statement of the case (SSOC). The Board remanded the instant matters in November 2011. As will be discussed herein, the Board finds that the agency of original jurisdiction (AOJ) substantially complied with the remand order with regard to the claims for service connection for hypertension and a back disorder and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In December 2010, the Veteran testified before the undersigned Veterans Law Judge sitting at the RO. A hearing transcript has been associated with the claims file. In the January 2012 Informal Hearing Presentation (IHP), the Veteran's representative raised a claim of entitlement to service connection for pseudofolliculitis barbae. This issue has not been adjudicated by the AOJ. Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. The issue of entitlement to service connection for a bilateral foot disorder is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. Hypertension is not shown to be causally or etiologically related to any disease, injury, or incident during service and did not manifest within one year of the Veteran's discharge from service. 2. A back disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service and arthritis did not manifest within one year of the Veteran's discharge from service. CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated by the Veteran's active duty service and may not be presumed to have been incurred in or aggravated by such service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. A back disorder was not incurred in or aggravated by the Veteran's active duty service and may not be presumed to have been incurred in or aggravated by such service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between a Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. Relevant to the claims adjudicated herein, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a January 2009 letter, sent prior to the initial March 2009 rating decision, advised the Veteran of the evidence and information necessary to substantiate his claims for service connection, as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, such letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Relevant to the duty to assist, the Veteran's service treatment records, service personnel records, VA treatment records, and the VA examination reports have been obtained and considered. The Board observes that the Veteran testified during his December 2010 hearing that he had received private treatment for his claimed disabilities, that he stated that he would submit such records and that the record was held open for 30 days to allow for the submission of such records. In January 2011, he submitted authorization and consent to release information forms to allow VA to make an attempt to obtain medical evidence relating to all the claims on appeal from a private hospital identified as Ben Taub General Hospital and VA Medical Centers. However, such forms indicate that they expire 180 days from the date signed. In the specific case, such authorization terminated 180 days from January 12, 2011, i.e., approximately mid-June 2011. Therefore, the Board remanded the case in November 2011 in order to allow the Veteran to identify any medical provider who treated him for his claimed disorders. Subsequent to the Board's remand, VA treatment records dated through August 2012 were obtained. Additionally, a November 2011 letter to the Veteran asked him to provide the names and addresses of all VA and non-VA health care providers who had treated him for the claimed disabilities, including for Ben Taub General Hospital. However, the Veteran has not submitted any records and did not complete an appropriate authorization form to allow VA to obtain such records. The Board emphasizes that "the duty to assist is not always a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, the Board finds that VA has satisfied its duty to assist in this regard. Additionally, the Veteran was afforded a VA examination in order to adjudicate his service connection claims. In this regard, the Board notes that the January 2012 VA examiner offered etiological opinions as to each claimed disorder and based his conclusions on interviews with the Veteran, a review of the record, and full examinations. Moreover, such opinions offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). In addition, and to the extent that the Veteran's representative has argued that the VA examinations were inadequate as the examiner reported that documentation of treatment for back complaints began in January 2012, the Board notes that there was no clinical documentation of such complaints in the record prior to this time. The December 2008 formal claim referenced by the Veteran's representative did not state when the Veteran's claimed back disorder began nor does it detail his symptoms. As such, the Board finds that the opinions proffered by the VA examiner are sufficient to assist VA in deciding the instant claims. Moreover, based on the foregoing, the Board determines that the AOJ has substantially complied with the November 2011 remand directives in obtaining the Veteran's service personnel records, securing all identified records, and affording the Veteran a VA examination, as applicable to the instant claims, and as such that no further action is necessary in this regard. See D'Aries, supra. Additionally, in December 2010, the Veteran was provided an opportunity to set forth his contentions during the hearing before the undersigned Acting Veterans Law Judge. In Bryant v. Shinseki, the Court held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). Here, during the December 2010 hearing, the undersigned Veterans Law Judge enumerated the issues on appeal. Also, information was solicited regarding the etiology of the Veteran's hypertension and back disorder, to include the Veteran's allegations that they are related to his military service. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. Id. at 497. Moreover, while the hearing discussion revealed additional records, the Board subsequently remanded the case in order to obtain them. As such, the Board finds that, consistent with Bryant, the undersigned Veterans Law Judge complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis Service connection may be granted 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(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including arthritis and cardiovascular-renal disease, to a degree of 10 percent within one year and three years, respectively, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. Hypertension Claim The Veteran contends that he began receiving treatment for hypertension during service and that he also received treatment for hypertension within one year of service discharge. A September 1974 service entrance examination was negative for any relevant abnormalities and the Veteran's blood pressure was measured to be 128/70. The Veteran denied high or low blood pressure in an accompanying entrance Report of Medical History (RMH). During service, his blood pressure was measured to be 130/68 in April 1975, 120/70 in June 1975, 112/64 in August 1975, 122/74 in December 1975, 120/80 in December 1975, 130/68 and 110/58 on repeat in February 1976, 110/60 in February 1976, 116/70 in June 1976 and 120/66 in July 1976. An August 1976 service discharge examination was negative for any relevant abnormalities and his blood pressure was measured to be 110/66. In an accompanying discharge RMH, the Veteran denied high or low blood pressure. He also denied having an illness or injury other than those already noted or that he had been treated by a health care practitioner within the past five years for other than minor illnesses. He also indicated that his health was good and that he was taking no medications. A September 1976 Statement of Medical Condition noted that there had been no change in the Veteran's medical condition since his last examination. Service personnel records were negative for complaints, treatments or diagnoses related to hypertension. An August 2009 VA treatment note reflected the Veteran's reports of suffering from hypertension for the past seven to eight years and an assessment of hypertension. This treatment was provided in conjunction with the Veteran's initial enrollment as a new patient in the VA system. During the December 2010 hearing, the Veteran testified that he first began having problems with hypertension and that had been prescribed medication to treat this hypertension during service. He stated that he did not mention that he was hypertensive at his service discharge examination as he was anxious to be discharged from service. He also indicated that sought treatment for his hypertension within three to four months of service discharge due to seeking employment. A January 2012 VA hypertension Disability Benefits Questionnaire (DBQ) reflected the Veteran's reports that he had been diagnosed with hypertension during service, that he used medication to treat his hypertension during service, and that he was placed on blood pressure medications within one year of service discharge. The examiner noted that the clinical evidence documented the Veteran's diagnosis of hypertension approximately nine years ago (i.e., 2003). Following an examination and a review of the Veteran's claims file, a diagnosis of hypertension was made. The examiner opined that it was less likely than not (less than 50/50) that the Veteran's hypertension had its onset during service as the clinical evidence of record documents the onset of hypertension about nine years ago, including by the Veteran's own statement to his treating physician upon entry into the VA system in 2009. The examiner noted that for hypertension to have been diagnosed during service, three elevated blood pressure readings times would need to be demonstrated over a short period of time; this was not shown in the Veteran's service treatment records as multiple blood pressure readings were normal. In addition, the examiner opined that the Veteran's hypertension was essential, and hence not caused by service as there was no end-organ pathology noted during service, which could account for hypertension which was not essential in nature. The Board has first considered whether service connection is warranted on a presumptive basis. However, the clinical evidence of record fails to show that the Veteran manifested hypertension to a degree of 10 percent within the one year following his active duty service discharge in September 1976. In addition, and as detailed below, the Board has found the Veteran's statements regarding his purported in-service treatment and diagnosis of hypertension as well as his statement of treatment within one year of service discharge to not be credible. As such, presumptive service connection is not warranted for hypertension. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted when all the evidence establishes a nexus between military service and current complaints. Degmetich v. Brown, 104 F. 3d 1328 (1997); Rabideau v. Derwinski, 2 Vet. App. 141 (1992). The medical evidence of record shows that the Veteran has a diagnosis of hypertension. However, the probative evidence of record demonstrates that the Veteran's hypertension is not related to his service. In this regard, the Board places great probative weight on the January 2012 VA examiner's opinion that the Veteran's hypertension was less likely than not related to service as he did not demonstrate elevated blood pressure readings or end-organ pathology during service. This opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Accordingly, as the probative evidence of records demonstrates that the current hypertension is not related to service, service connection is not warranted. The Board notes that the Veteran has contended on his own behalf that his current hypertension is related to his service. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's hypertension and any instance of his service to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Additionally, in a single-judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation to establish that the appellant suffered from an event, injury or disease in service." Richardson v. Shinseki, No. 08-0357, slip. op. at 4 (Vet. App. May 10, 2010). While the Board recognizes that such single judge decisions carry no precedential weight, they may be relied upon for any persuasiveness or reasoning they contain. See Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992). Here, while the Veteran is competent to describe his purported diagnosis and treatment of hypertension during service as well as his current manifestations of hypertension, the Board accords his statements regarding the etiology of such disorder little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the diagnosis of hypertension requires the administration and interpretation of blood pressure readings. There is no indication that the Veteran possesses the requisite medical knowledge to take blood pressure readings or interpret their results. Moreover, the Veteran has offered only conclusory statements regarding the relationship between his in-service hypertension complaints and his current hypertension. In contrast, the January 2012 VA examines took into consideration all the relevant facts in providing an opinion, to include the Veteran's contended in-service diagnosis and treatment of hypertension as well as the current nature of his hypertension. Therefore, the Board accords greater probative weight to the VA examiner's opinion. In addition, in adjudicating this claim, the Board must assess not only competency of the Veteran's statements, but also their credibility. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The Board notes that the Veteran testified during his December 2010 hearing that he had received treatment for hypertension during service and that he had been prescribed medication to treat the condition. He further alleged that he has experienced hypertension since such time. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). In the instant case, the Board finds such statements to lack credibility as they are inconsistent with the other evidence of record and were made under circumstances indicating bias or interest and, therefore, accords no probative weight to such contentions. In this regard, the Veteran denied taking medications and that he had suffered from high blood pressure at his August 1976 service discharge. He also denied that he had been treated by a health care practitioner within the past five years for other than minor illnesses. The Board notes that the Veteran's August 1976 statements were made many years prior to the filing of the instant claim for service connection, and are highly probative as they are contemporaneous with the time in question. Moreover, the Veteran himself reported that he had suffered from hypertension for seven or eight years (i.e. since 2002 or 2003) in an August 2009 VA treatment note. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment); see also Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). Additionally, the Veteran did not report an in-service treatment or complaints referable to hypertension until he filed a claim for VA benefits in December 2008. Therefore, in light of these inconsistent statements, the Board finds the Veteran's statements regarding a continuity of symptomology, his in-service onset and his treatment within one year of service discharge to not be credible. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for hypertension. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. B. Back Disorder The Veteran contends that he injured his back while changing a tire during service and that his current back disorder was caused by this injury. A September 1974 service discharge examination was negative for any relevant abnormalities and the Veteran denied recurrent back pain in an accompanying RHM. An August 1976 service discharge examination was negative for any relevant abnormalities. In an accompanying discharge RMH, the Veteran denied recurrent back pain. He also denied having an illness or injury other than those already noted or that he had been treated by a health care practitioner within the past five years for other than minor illnesses. A September 1976 Statement of Medical Condition noted that there had been no change in the Veteran's medical condition since his last examination. The remaining service treatment records were negative for complaints, treatments or diagnoses related to any back disorder. Service personnel records were negative for complaints, treatments or diagnoses related to a lumbar spine disorder. During the December 2010 hearing, the Veteran testified that he injured his back during service after hitting it on a truck while changing a tire and lifting the tire. He did not seek treatment for this injury as he attempted "to man up to it" and was afraid that it would negatively impact his career. However, he indicated that he sought treatment for his back within one year of service discharge and has experienced back pain intermittently since service. A January 2012 VA treatment note reflected the Veteran's complaints of intermittent low back pain for years. A January 2012 VA back DBQ reflected the Veteran's reports of hitting his back on a five ton truck while performing maintenance activities, specifically that he struck his back while picking up a tire. He denied undergoing an evaluation or sustaining other back injuries. Following a physical examination and a review of the Veteran's claims file, a diagnosis of degenerative joint disease (DJD) of the lumbar spine was made, with the examiner noting that early facet DJD was present on a January 2012 lumbar X-ray. The examiner then opined that it was less likely than not (less than 50/50) that the Veteran's current back disorder was related to service as there was no evidence of ongoing back issues during service or at service discharge and the first clinical evidence of back complaints was noted earlier this month. The examiner further opined that due to the long interim without complaints related to the Veteran's back, there would be "no nexus to link the present back problem" to service and the recent onset of back complaints were more likely related to aging and occupational stresses (such as that of a truck driver). In addition, the examiner noted that the Veteran's recent complaints correlated with an aging and occupational cause. The Board has first considered whether service connection is warranted on a presumptive basis. However, the clinical evidence of record fails to show that the Veteran manifested arthritis to a degree of 10 percent within the one year following his active duty service discharge in September 1976. In addition, while the Veteran alleged seeking treatment for back pain in the first year after service, he has not reported that arthritis was present at such time. As such, presumptive service connection is not warranted for arthritis of the back. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted when all the evidence establishes a nexus between military service and current complaints. Degmetich, supra; Rabideau, supra. The medical evidence of record shows that the Veteran has a diagnosis of lumbar DJD. However, the probative evidence of record demonstrates that the Veteran's lumbar DJD is not related to his service. In this regard, the Board places great probative weight on the January 2012 VA examiner's opinion that the Veteran's lumbar DJD was less likely than not related to service as there was no evidence of ongoing back issues during service or post-service until 2012 and that his disorder correlated to aging and occupational causes. This opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Accordingly, as the probative evidence of records demonstrates that the current lumbar DJD is not related to service, service connection is not warranted. The Board notes that the Veteran has contended on his own behalf that his current lumbar DJD is related to his service. As previously noted, lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno, supra. Lay evidence may also be competent to establish medical etiology or nexus. Davidson, supra. However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters, supra. In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's lumbar DJD and any instance of his service to be complex in nature. See Woehlaert, supra. Additionally, in a single-judge Memorandum Decision issued by the Court, it was noted that "in the absence of any medical evidence, the record must provide some evidence beyond an appellant's own conclusory statements regarding causation to establish that the appellant suffered from an event, injury or disease in service." Richardson, supra. Here, while the Veteran is competent to describe his purported in-service back symptoms and injury as well as his current manifestations of lumbar DJD, the Board accords his statements regarding the etiology of such disorder little probative value as he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones, supra. In this regard, the question of causation of a back disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. There is no indication that the Veteran possesses the requisite medical knowledge to offer an opinion regarding the etiology of back disorder. Moreover, the Veteran has offered only conclusory statements regarding the relationship between his purported in-service back injury and/or symptoms and his current lumbar DJD. In contrast, the January 2012 VA examiner took into consideration all the relevant facts in providing an opinion, to include the type of the Veteran's purported in-service injury and/or symptoms and the current nature of his lumbar DJD. Therefore, the Board accords greater probative weight to the VA examiner's opinion. In addition, in adjudicating this claim, the Board must assess not only competency of the Veteran's statements, but also their credibility. See Buchanan, supra. The Board notes that the Veteran testified during his December 2010 hearing that he injured his back during service but did not seek treatment, in part because he feared such treatment would negatively impact his military career. He further alleged that he sought treatment within one year of his service discharge, and has experienced back pain, albeit intermittently, since such time. In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza, supra. In the instant case, the Board finds such statements to lack credibility as they are inconsistent with the other evidence of record and were made under circumstances indicating bias or interest and, therefore, accords no probative weight to such contentions. In this regard, the Veteran denied having recurrent back pain or having sustained an injury other than those noted at his August 1976 service discharge examination, which represented the close of his military career. He also denied that he had been treated by a health care practitioner within the past five years for other than minor illnesses. The Board notes that the Veteran's August 1976 statements were made many years prior to the filing of the instant claim for service connection, and are highly probative as they are contemporaneous with the time in question. In addition, the Veteran did not report a history of back pain in August 2009 when he entered the VA system as a new patient, but did report his history of hypertension, obstructive sleep apnea and colon polyps. See Rucker, supra; Williams, supra. Additionally, the Veteran did not report an in-service injury, treatment within one year of discharge, or complaints referable to his back until he filed a claim for VA benefits in December 2008. Therefore, in light of these inconsistent statements, the Board finds the Veteran's statements regarding a continuity of symptomology, his in-service onset and his treatment within one year of service discharge to not be credible. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a back disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for hypertension is denied. Service connection for a back disorder is denied. REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim for service connection for a bilateral foot disorder so that he is afforded every possible consideration. Once the Secretary undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, he must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). VA regulations provide that where an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. 38 C.F.R. § 4.2; see 38 C.F.R. § 19.9. Where the Board makes a decision based on an examination report which does not contain sufficient detail, remand is required "for compliance with the duty to assist by conducting a thorough and contemporaneous medical examination." Goss v. Brown, 9 Vet. App 109, 114 (1996); Stanton v. Brown, 5 Vet. App. 563, 569 (1993). The Veteran asserts his bilateral foot disorder is the result of wearing boot blouses or boots during service. He also testified during his December 2010 hearing that wearing such boot blouses during service caused his toenails to become embedded under his skin. In a January 2012 VA DBQ, the examiner diagnosed the Veteran with bilateral pes planus and bilateral foot degenerative joint disease. The examiner opined that it was less likely than not that the Veteran's foot condition was related to service as he was born with a flat foot and there was no proof of aggravation during service. The examiner also opined that the Veteran's foot DJD was the result of aging and occupational stress. However, the examiner did not determine whether the Veteran's bilateral pes planus was a congenital disease or defect. In this regard, the Board notes that the Veteran's feet were found to be normal on service entrance. In this regard, it is unclear whether the Veteran's bilateral pes planus was considered a congenital or developmental defect or disease. VA's General Counsel has indicated that there is a distinction between a congenital or developmental "disease" and a congenital "defect" for service connection purposes. Congenital diseases may be recognized as service connected if the evidence as a whole shows aggravation in service within the meaning of VA regulations. 38 C.F.R. § 3.306. However, congenital or developmental defects are not service connectable in their own right, although service connection may be granted for additional disability due to disease or injury superimposed upon a defect during service. VAOPGCPREC 82-90 (1990). Therefore, as to the Veteran's bilateral pes planus, the examiner is requested to offer an opinion regarding: (i) whether it constitutes a congenital defect, and, if so, whether there is any additional disability due to a superimposed disease or injury during service; or (ii) whether it constitutes a congenital disease, and, if so, whether it was aggravated by his period of active service beyond the natural progression. Accordingly, the case is REMANDED for the following action: 1. Return the claims file, to include a copy of this remand, to the January 2012 VA examiner for an addendum opinion. If the examiner who drafted the January 2012 opinion is unavailable, the opinion should be rendered by another appropriate medical professional. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. Following a review of the claims file, the examiner is asked to furnish an opinion with respect to the following questions: a) With regard to the Veteran's bilateral pes planus, does it constitute a defect or a disease, as defined by VAOPGCPREC 82-90 (generally, a congenital abnormality that is subject to improvement or deterioration is considered a disease)? b) If the Veteran's bilateral pes planus is considered a defect, was there any superimposed disease or injury in connection with the congenital defect? The examiner should comment on the Veteran's contention that his boot or boot blouse resulted in his bilateral foot disorder, including his reported embedded toenails. c) If the examiner finds that the Veteran's bilateral pes planus is a disease, then is it at least as likely as not that it was aggravated by his period of active service? Aggravation indicates a permanent worsening of the underlying condition as compared to an increase in symptoms. If aggravation is found, the examiner should attempt to quantify the extent of additional disability resulting from the aggravation. In answering each of the questions posed above, the examiner is advised that the Veteran is competent to report injuries and symptoms, and that his reports must be considered in formulating the requested opinion. A complete rating should be given for each opinion expressed. In this regard, a discussion of the facts and medical principles involved would be considerable assistance to the Board. 2. After completing the above actions, to include any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran's claim should be readjudicated based on the entirety of the evidence. If the claim remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. The Board intimates no opinion as to the outcome of this case. The Veteran need take no action until so informed. The purpose of this REMAND is to ensure compliance with due process considerations. The Veteran has the right to submit additional evidence and argument on the matter 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). ______________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs