Citation Nr: 1306173 Decision Date: 02/22/13 Archive Date: 02/27/13 DOCKET NO. 10-13 819 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUE Whether new and material evidence has been received to reopen a service connection claim for gout, and if so, whether service connection is warranted. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Sarah Richmond, Counsel INTRODUCTION The Veteran had active military service from July 1968 to July 1972. This matter comes to the Board of Veterans' Appeals (Board) from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which denied the petition to reopen a claim of service connection for gout finding that evidence received was not new and material. In September 2009, the RO determined that new and material evidence had been received to reopen the claim, but denied the Veteran's claim on the merits. Irrespective of the RO's action, the Board must decide whether the Veteran has submitted new and material evidence to reopen the claim of service connection for gout. Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). In May 2012, the Veteran testified before the undersigned Veterans Law Judge at a Board videoconference hearing at the RO. FINDINGS OF FACT 1. The Veteran's original service connection claim for gout was denied in an October 2006 RO decision. The Veteran did not appeal this decision to the Board. 2. The evidence received since the October 2006 RO decision is not duplicative or cumulative of evidence previously of record and raises a reasonable possibility of substantiating the claim for service connection for gout. 3. The preponderance of the evidence does not establish that the Veteran's gout had its onset in service, or that his gout is otherwise related to his active military service to include an in-service leg injury and infection (including the medication used to treat the infection). CONCLUSIONS OF LAW 1. The October 2006 RO decision that denied entitlement to service connection for gout is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.1103 (2012). 2. Evidence received since the October 2006 RO decision that denied entitlement to service connection for gout is new and material, and the claim is reopened. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156 (2012). 3. The Veteran's gout was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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 C.F.R. § 3.159(b). This notice must be provided prior to an initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ). Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Veteran has received all essential notice, has had a meaningful opportunity to participate in the development of his claim, and is not prejudiced by any technical notice deficiency along the way. See Conway v. Principi, 353 F.3d 1369 (Fed. Cir. 2004). An RO letter dated in February 2009 informed the Veteran of all of the elements required by 38 C.F.R. § 3.159(b), as stated above. As such, the February 2009 and October 2009 letters satisfied VA's duty to notify. Regarding the duty to assist, the RO has obtained the Veteran's service treatment records, VA treatment records, Social Security Administration (SSA) records, and some private treatment records. The Veteran mentioned in a November 2009 statement on a VA Form 21-4138 that VA had not considered records from Shiland Medical Center. The claims file demonstrates, however, that records from this facility were obtained as part of his previous claim filed in 2008 and that these records were in fact considered as part of the evidence of record. The RO also has provided him with a VA examination in October 2009 and addendum opinion in January 2010. The examination report and opinion obtained contains sufficient information to decide the issue on appeal and further examination is not necessary. See Massey v. Brown, 7 Vet. App. 204 (1994). The duty to assist has therefore been satisfied and there is no reasonable possibility that any further assistance to the Veteran by VA would be capable of substantiating his claim. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Because VA's duties to notify and assist have been met, there is no prejudice to the Veteran in adjudicating this appeal. II. New and Material Evidence The Veteran's claim of entitlement to service connection for gout was originally denied by an October 2006 RO decision on the grounds that the condition was not manifest in service, nor was it aggravated or caused by service. The service treatment records show that the Veteran was treated for a laceration to the left leg, which became infected in April 1971. Post-service evidence included private treatment records from Shiland Family Practice dated in September 1998 indicating that the Veteran had been treated for gout for the last 15 years. In denying the claim in October 2006, the RO noted that the available scientific and medical evidence did not support the conclusion that the Veteran's gout was associated with herbicide exposure. Notice of the rating decision and the Veteran's appellate rights was dated October 25, 2006. The Veteran filed a notice of disagreement with this decision in November 2006. Thereafter, the RO sent the Veteran a statement of the case (SOC) dated March 2, 2007. The SOC noted that the Veteran had 60 days from the date of the SOC or the remainder of the one year period from the date of notice of rating decision on appeal to respond by filing a VA Form 9. However, the Veteran did not respond within this time frame; i.e., by October 25, 2007. Thus, the October 2006 decision is final. See 38 U.S.C.A. § 7105; 38 C.F.R. § 20.1103. The Veteran submitted an application to reopen service connection for gout in December 2008. Service connection is established where a particular injury or disease resulting in disability was incurred in the line of duty in active military service or, if pre-existing such service, was aggravated during service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). A veteran may be granted service connection for any disease initially diagnosed after discharge, but only if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The U.S. Court of Appeals for Veterans Claims (CAVC or Court) has held that in order to prevail on the issue of service connection on the merits, there must be medical evidence of a (1) current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247, 253 (1999). A previously denied claim may be reopened by the submission of new and material evidence. 38 U.S.C.A. § 5108; 38 C.F.R. 3.156. Evidence is new if it has not been previously submitted to agency decisionmakers. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). Evidence is material if it, either by itself or considered in conjunction with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be cumulative or redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. In this regard, the Board notes that, in a recent case, the Court clarified that the phrase "raises a reasonable possibility of substantiating the claim" is meant to create a low threshold that enables, rather than precludes, reopening. Shade v. Shinseki, 24 Vet. App. 110 (2010). Specifically, the Court stated that reopening is required when the newly submitted evidence, combined with VA assistance and considered with the other evidence of record, raises a reasonable possibility of substantiating the claim. Id. Additional evidence obtained since the October 2006 RO decision includes an opinion provided by a private physician in December 2008 that the Veteran's leg injury in service may be related to his complaints of gout. Evidence of a medical opinion relating the Veteran's gout to his military service was not previously considered by VA and supports the presence of a current disability related to military service, which was not of record in the prior denial in October 2006. The Veteran's wife's statement in November 2008 and the Veteran's testimony presented at the Board hearing in May 2012 also reflect competent assertions of the severity of the leg injury and subsequent infection in service and symptomatology noticed in the foot within a few years after the Veteran's discharge. When considering the new evidence, combined with other evidence of record, there is, at least, a reasonable possibility of substantiating the claim. Thus, the evidence meets the standard noted in Shade for reopening the claim based on new and material evidence. As the additional evidence is new and material, the claim of entitlement to service connection for gout is reopened. 38 U.S.C.A. § 5108; 38 C.F.R. § 3.156(a). III. Service Connection Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection can be demonstrated for a disease diagnosed after service 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); Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994) (holding that proof of direct service connection may entail proof that exposure during service caused the malady that appeared many years later); Cosman v. Principi, 3 Vet. App. 503, 505 (1992) (holding that service connection can still be established even when a Veteran did not have a particular condition diagnosed during service or for many years thereafter). In order to establish service connection, the evidence must generally show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); see generally 38 C.F.R. § 3.303. Alternatively, under 38 C.F.R. § 3.303(b), the second and third Shedden/Caluza elements can be established through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr, 21 Vet. App. at 307. Symptoms, and not treatment, are the essence of any evidence of continuity of symptomatology. Savage, 10 Vet. App. at 496. The third Barr/Savage element is not equivalent to the third Shedden/Caluza element, as requiring medical nexus evidence under 38 C.F.R. § 3.303(b) would nullify that regulation. Id. at 497. However, it does not follow that any present disability is necessarily related to any demonstrated continuous symptomatology. Id. Therefore, in Savage, the Court held that competent evidence is required to demonstrate a relationship between the continuous symptoms and the presently diagnosed disability. Id. (explaining that "medical evidence is required to demonstrate such a relationship unless such a relationship is one to which a layperson's observation is competent"). 38 U.S.C.A. § 1154(a) requires VA to give "due consideration" to "all pertinent medical and lay evidence" when evaluating a claim for disability benefits. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Generally, the Board should determine whether the Veteran's particular disability is the type of disability for which lay evidence is competent, and, if so, weigh that evidence against the other evidence of record in making its determinations. Kahana v. Shinseki, 24 Vet. App. 428, 433 n.4 (2011). The Federal Circuit has held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). "Sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer." Jandreau, 492 F.3d at 1377, n4. A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Lastly, a layperson may also be competent to testify to the manifestations of a chronic condition during service or a presumptive period or to continuity of symptomatology. Hickson, 12 Vet. App. at 253. A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, and has a disease listed at § 3.309(e) shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. §§ 3.307(a)(6); 38 C.F.R. § 3.313(a). If a veteran was exposed to an herbicide agent during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, the following diseases shall be service-connected, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C.A. § 1113 and 38 C.F.R. § 3.307(d) are also satisfied: chloracne or other acneform disease consistent with chloracne; type II diabetes (also known as Type II diabetes mellitus or adult- onset diabetes) Hodgkin's disease; multiple myeloma; non- Hodgkin's lymphoma; acute and subacute peripheral neuropathy; PCT; prostate cancer; respiratory cancers (cancer of the lung, bronchus, larynx, or trachea); and soft-tissue sarcomas (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). 38 C.F.R. § 3.309(e). The Secretary of VA has determined that there is no positive association between exposure to herbicides and any other condition for which the Secretary has not specifically determined that a presumption of service connection is warranted. See Diseases Not Associated With Exposure to Certain Herbicide Agents, 61 Fed. Reg. 41442, 41448 (1996). Nevertheless, the United States Court of Appeals for the Federal Circuit ("Court") has held that the Veteran's Dioxin and Radiation Exposure Compensation Standards Act, Pub. L. No. 98-542, § 5, 98 Stat. 2725, 2727-29 (1984), does not preclude a claimant from establishing service connection with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). The rationale employed in Combee also applies to claims based on exposure to herbicide exposure. Brock v. Brown, 10 Vet. App. 155 (1997). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). Moreover, the United States Court of Appeals for Veterans Claims (Court) has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992). As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also 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."). Turning now to the facts of this case, the Veteran contends that he has gout due to an infection in his leg that became gangrenous in service. He testified at the May 2012 Board hearing that he was first diagnosed with gout in 1981 but that he first noticed symptoms of gout in 1975. He said that when his gout was diagnosed his foot had a lot of swelling and discoloration. He recalled that he was treated for about 45 days while in service for the infection in his legs and that a private doctor, Dr. Sweet, told him that the medication used to treat the leg infection damaged his kidneys, which caused an increase in uric acid and led to his gout. The Veteran's wife also submitted a statement in November 2008 noting that she recalled in the late 1970s early 1980s that the Veteran developed pain and swelling in his feet and legs. She also recalled that even though the service treatment records only noted a cut and dressing changes, the wound was quite severe and required over 100 stitches. She also indicated that the Veteran had been in the hospital for over a month because the wound was infected and had gangrene and he was just a few days from having the leg amputated. The service treatment records are negative for any findings of gout, which is consistent with the Veteran's statements that he did not notice gout until a few years after service in 1975. The treatment records do note that he had a staphylococcus epidermidis infection in April 1971 from a laceration to the leg on a bar stool in Vietnam. The treatment record notes that injury occurred on April 3, 1971 and that the laceration was six inches on the calf of the left leg and down to the muscle in the shape of a "v". During a dressing change on April 10, 1971, it was noted that there was some infection. The wound was redressed and cleaned on multiple occasions through the rest of the month in April 1971. By May 1971, it was noted that the wound was healing well. A May 13, 1971 note indicates that the Veteran's father had sent a message noting his concern over the drugs used to treat the Veteran. It was noted that the Veteran had been treated with antibiotics for an infected laceration. He had initially been treated with tetracycline but this was changed to Prostaphlin when a culture taken from the infection site showed staphylococcus aureus. The laceration was responding to treatment and healing well when last evaluated on May 12, 1971. Based on the evidence in the service treatment records, the Board acknowledges that even though there are no findings of gout, the Veteran incurred a leg injury in service that became infected. The inquiry that follows is whether there is medical evidence of a current gout disability. After service, records from Shiland Family Medicine dated in September 1998 note that the Veteran had had gout for 15 years, so since approximately, 1983. Another private treatment record notes gout since 1980. The Veteran was examined by a VA examiner in October 2009 and at that time the examiner determined that although there were no objective findings of active gout on examination, the Veteran's clinical history was highly suggestive of gout. As the record shows an in-service injury to the leg with an infection and post-service diagnoses of gout, the determinative issue in this case is whether there is any relationship between these. In December 2008, the Veteran's private physician gave an impression that the Veteran's leg injury might be related to his chief complaints of gout and PTSD. The Veteran testified at the hearing that the physician who provided this opinion had physically examined him and that the Veteran had provided his medical history to the physician. The Veteran was afforded a VA examination in October 2009. The examiner provided a summary of the Veteran's relevant medical history and noted his in-service treatment for the leg injury with infection. It was noted that the main complication from the leg injury was a scar. (As an aside, the Board notes that the Veteran is service-connected for the scar on the leg.) It was noted that there were no recurrent infections in the leg since the infection in service. The gout flared in the feet approximately three times per year. The examiner determined that it was less likely that the Veteran's gout had any relationship with this leg injury in service. The examiner noted the private medical opinion above but determined that he thought the private physician was merely stating the Veteran's comorbidities; but that if the private physician was assessing a relationship between the Veteran's gout and service, he disagreed. The examiner's rationale was that there was no medical data or evidence whatsoever that could possibly link these two abnormalities, as gout was a completely separate entity from a previous leg injury. A supplemental opinion was provided in January 2010. It was noted that the Veteran had been treated in service in April 1971 for a laceration to the left leg and had developed a staphylococcus infection, which was treated initially with tetracycline and then with Prostaphlin. It was noted that numerous follow-up treatment records noted the Veteran's wound and infection, including many dressing changes. In July 1972, the Veteran underwent a physical examination and gave a negative history of arthritic complaint, and was felt to have a normal examination. The examiner went on to note that he had reviewed the opinion of the previous examiner in October 2009 and that he concurred with it in every regard. Based on the foregoing, the Board finds that the preponderance of the evidence shows that the Veteran's gout is not related to any event in service. Initially, the Board notes that the Veteran had service in Vietnam and thus was presumably exposed to herbicides in service. However, the Veteran has made it clear that he is not asserting that his gout was due to herbicides exposure, but rather to his leg injury and resultant infection and medications used to treat the infection in service. The Board also notes that there is no medical evidence linking the Veteran's gout to his presumed exposure to herbicides. The Board acknowledges that the Veteran was competent to report that he had continued to experience symptoms in his feet since after service in 1975. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007) (holding that lay testimony is competent to establish the presence of observable symptomatology); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). The Veteran was also competent to report that he suffered injury to his leg in service. See Washington v. Nicholson, 19 Vet. App. 362 (2005) (holding that a Veteran is competent to report what occurred during service because he is competent to testify as to factual matters of which he has first-hand knowledge). Competent testimony is limited to that which the witness has actually observed and is within the realm of his personal knowledge; such knowledge comes to a witness through use of his senses-that which is heard, felt, seen, smelled, or tasted. Layno v. Brown, 6 Vet. App. 465 (1994). It was within the Veteran's realm of personal knowledge whether he was treated for his leg in service and that he sought treatment for his gout since the 1980s, and had continued to experience symptomatology in his feet since after service in 1975. The Veteran's statements also are credible as they have been consistent throughout the record and are also consistent with the medical evidence of record showing the laceration injury to the leg in service with resultant infection and the diagnosis of gout since approximately 1980. The Veteran's assertions that his gout is related to his leg injury in service are not enough to substantiate his claim, however. There must be competent medical evidence or opinion to corroborate these contentions. See 38 C.F.R. § 3.159(a)(1) (competent medical evidence means evidence provided by a person who is qualified through education, training or experience to offer medical diagnoses, statements, or opinions). The Veteran's opinions are insufficient to provide the requisite nexus between an in-service injury and any current disability because, as a lay person, he was not competent to establish a medical etiology merely by his own assertions; such matters require medical expertise. See 38 C.F.R. § 3.159(a)(1); Duenas v. Principi, 18 Vet. App. 512, 520 (2004); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997) (holding that a layperson is generally not capable of providing opinions on matters requiring medical knowledge, such as the condition causing or aggravating the symptoms); see also Bostain v. West, 11 Vet. App. 124, 127 (1998); Stadin v. Brown, 8 Vet. App. 280, 284 (1995); Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). As such, his statements regarding the etiology of any gout are merely speculation as to a possible cause as he was not medically qualified to prove a matter requiring medical expertise, such as an opinion as to medical causation. In addressing the medical opinions of record, the Board finds the VA medical opinion in October 2009 with addendum opinion in January 2010 to be more probative as to the etiology of the current gout than the opinion provided in December 2008. The October 2009 VA examiner reviewed the claims file and examined the Veteran and found that his current gout was not related to his military service. The examiner noted the Veteran's injury to the leg in service, but found that the Veteran's leg injury was a completely separate entity from his gout. It was noted that there was no recurrence of leg infection after the initial infection in service and that there were no arthritic complaints in service. The addendum opinion in January 2010 additionally noted the prolonged treatment of the leg in service and infection and the medication used to treat the infection; but the examiner still determined that he concurred completely with the previous determination that there was no relationship between the Veteran's gout and his leg injury in service. Thus, the examiners have addressed the Veteran's contention that his gout was related to not only the leg injury in service, but the medication used to treat the leg infection. The examiners were fully informed of the pertinent medical history of the case, including the Veteran's assertions of gout due leg injury and medication used to treat the infection; they provided fully articulated opinions; and the opinions were supported by a reasoned analysis. Therefore, the Board assigns a high probative value to the October 2009 medical opinion and addendum opinion provided in January 2010. See Nieves-Rodriguez, 22 Vet. App. 295, 303-04 (2008); see also 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."); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The December 2008 private physician's opinion was more equivocal in nature, in that the physician noted that the leg complaints might be related to his gout. There also is no rationale provided for this opinion. Therefore, it has less probative value. Id. As such, after weighing and balancing the evidence of record, the Board finds that the preponderance of the evidence of record is against a finding that the Veteran's current gout had its onset during active service or is related to any in-service disease, event, or injury. See 38 U.S.C.A. § 1110. Accordingly, the Board finds that the criteria for service connection for gout are not met. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. See 38 U.S.C.A. § 5107(b). However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). ORDER Entitlement to service connection for gout is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs