Citation Nr: 1309604 Decision Date: 03/21/13 Archive Date: 04/01/13 DOCKET NO. 09-18 885 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Salt Lake City, Utah THE ISSUE Entitlement to service connection for a bilateral foot disorder, to include bilateral pes planus, pes varus/valgus, plantar fasciitis and bilateral calcaneal bone spurs. WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from November 1978 to March 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Salt Lake City, Utah which, in pertinent part, denied the Veteran's claims for service connection for flat feet and bone spurs. A review of the Virtual VA claims processing system does not reveal any documents pertinent to the present appeal. The Veteran testified before the undersigned Acting Veterans Law Judge (AVLJ) at a March 2010 RO (Videoconference) hearing. A hearing transcript has been associated with the claims file. The Board remanded the instant matter for additional development in May 2010 and March 2012. In addition, the Board recharacterized the instant matter in March 2012 to more accurately reflect the evidence of record and the Veteran's complaints of symptomatology as well as to comport with the holding in Clemons v. Shinseki, 23 Vet. App. 1 (2009). In September 2012, the Board sought an opinion as to the instant claim from the Veterans Health Administration (VHA). Such an opinion was obtained in November 2012. The Veteran was provided a copy of this opinion in November 2012 and provided an additional 60-day period to provide additional evidence and/or argument. FINDINGS OF FACT 1. The evidence of record does not substantiate or establish the existence of a current bilateral pes planus. 2. The evidence of record clearly and unmistakably shows that the Veteran had metatarsus adductus and left leg internal tibial torsion that preexisted his period of service and clearly and unmistakably did not permanently increase in severity as a result of his service. 3. Bone or heel spurs, plantar fasciitis and pes valgus are not shown to be causally or etiologically related to any disease, injury, or incident during the Veteran's service. CONCLUSION OF LAW A bilateral foot disorder, to include bilateral pes planus, pes varus/valgus, plantar fasciitis and bilateral calcaneal bone spurs, was not incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1111, 1131, 1153, 5103, 5103A, 5107 (West 2002); 38 C.F.R. § 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. The Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claim decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II), the United States Court of Appeals for Veterans Claims (Court) held that 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. Prior to initial adjudication of the Veteran's claim, a letter dated in October 2007 fully satisfied the duty to notify provisions. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, at 187. As the Board has concluded that the preponderance of the evidence is against the claim for service connection, any questions as to the appropriate disability rating or effective date to be assigned are rendered moot, and no further notice is needed. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). All the law requires is that the duty to notify is satisfied and that claimants are given the opportunity to submit information and evidence in support of their claim. Once this has been accomplished, all due process concerns have been satisfied. See Bernard v. Brown, 4 Vet. App. 384 (1993); Sutton v. Brown, 9 Vet. App. 553 (1996); see also 38 C.F.R. § 20.1102 (harmless error). In view of the foregoing, the Board finds that the Veteran was notified and aware of the evidence needed to substantiate his claim, as well as the avenues through which he might obtain such evidence, and of the allocation of responsibilities between himself and VA in obtaining such evidence. Accordingly, there is no further duty to notify. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and various private treatment records are in the claims file. The Veteran has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The record indicates that the Veteran participated in VA podiatry examinations, the results of which have been included in the claims file for review. In addition, the Board has also obtained a VHA opinion based upon review of the entire claims folder and a factual history that has been accepted as true by the Board. The opinion received, dated November 2012, considers the Veteran's pre-service medical history, contentions regarding his in-service injury and comprehensively analyzes the facts of this case, to include consideration of medical treatise information and the significance of the Veteran's report of chronic foot pain since service. This examination is clearly adequate for rating purposes. Additionally, in February 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 February 2010 hearing, the undersigned Acting Veterans Law Judge enumerated the issue on appeal. Also, information was solicited regarding the etiology of the Veteran's bilateral foot disorder, to include the Veteran's allegations that it was 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. The undersigned Acting Veterans Law Judge informed the Veteran that he could obtain a copy of his claims file to permit his personal physician to review the record. Moreover, while the hearing discussion revealed the Veteran had obtained pertinent medical research from the internet, the Veteran was asked to forward such information to the Board and the record was held open for 30 days to allow such a submission. As such, the Board finds that, consistent with Bryant, the undersigned Acting 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. Additionally, the Board finds there has been substantial compliance with its May 2010 and March 2012 remand directives. The Appeals Management Center (AMC) sought specific private treatment records and scheduled the Veteran for a VA examination, which he attended. The Court recently noted that "only substantial compliance with the terms of the Board's engagement letter would be required, not strict compliance." See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); see also Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no Stegall (Stegall v. West, 11 Vet. App. 268) violation when the examiner made the ultimate determination required by the Board's remand.) The Board finds that the AMC substantially complied with the mandates of its remands. See Stegall, supra, (finding that a remand by the Board confers on the Veteran the right to compliance with its remand orders). Given the foregoing, the Board finds that the VA has substantially complied with the duty to obtain the requisite medical information necessary to make a decision on the Veteran's claim. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). The Veteran has submitted argument and evidence in support of the appeal. Based on the foregoing, the Board finds that the Veteran has had a meaningful opportunity to participate in the adjudication of his claim such that the essential fairness of the adjudication is not affected. II. Pertinent Laws and Regulations Service connection is established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during periods of active wartime service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.309(a). In general, service connection requires a claimant to satisfy a three element test: (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 - the so-called 'nexus' requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In some circumstances, certain chronic diseases listed at 38 C.F.R. § 3.309(a) may be presumed to have been incurred in service if manifest to a compensable degree within one year from discharge from service, provided further that the rebuttable presumption provisions of 38 C.F.R. § 3.307 are also satisfied. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. § 3.309(b). For the showing of chronic disease in service, there are required a combination of manifestations sufficient to identify a disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. 38 C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service is not, in fact, shown to be chronic or when the diagnosis of chronicity may be legitimately questioned. Id. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. However, the continuity and chronicity provisions of 38 C.F.R. § 3.303(b) only apply to the chronic diseases enumerated in 38 C.F.R. § 3.309(a). Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013), overruling Savage v. Gober, 10 Vet. App. 488, 495-96 (1997) (applying 38 C.F.R. § 3.303(b) to a chronic disease not listed in 38 C.F.R. § 3.309(a) as "a substitute way of showing in-service incurrence and medical nexus.") Relevant to this claim, arthritis is among the list of chronic disease listed within 38 C.F.R. § 3.309(a). The diagnoses of pes planus, pes varus/valgus, calcaneal spurs, metatarsus abductus and internal tibial torsion are not among the list of chronic diseases under 38 C.F.R. § 3.309(a). A veteran who served during a period of war, or after December 31, 1946, will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior to service and was not aggravated by such service. 38 U.S.C.A. § 1111. When the presumption of soundness attaches to a claim but there is a question of preexisting disability, VA has the burden of establishing by clear and unmistakable evidence (1) that a disability preexisted service and (2) that there was no aggravation during service. Wagner v. Principi, 370 F. 3d 1089, 1096 (2004). A preexisting injury or disease will be considered to have been aggravated during 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. However, aggravation of a preexisting injury or disease will not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. § 3.306. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence aggravation unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). In Wagner, the Federal Circuit described the framework for analyzing a claim involving 38 U.S.C.A. § 1111 in conjunction with the provisions of 38 U.S.C.A. § 1153 as follows: The effect of section 1111 on claims for service-connected disability thus may be summarized as follows. When no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both preexisting and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any "increase in disability [was] due to the natural progress" of the preexisting condition. Id. at 1096. VA's Office of General Counsel has issued a precedent opinion holding that in order to rebut the presumption of soundness in 38 U.S.C.A. § 1111, VA must demonstrate by clear and unmistakable evidence both that the disease or injury in question existed prior to service and that it was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA's duty under the second prong of this rebuttal standard attaches. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. III. Merits of the Claim A. Factual Background An October 1978 service entrance examination was negative for any relevant abnormalities and the Veteran denied foot trouble in any accompanying Report of Medical History (RMH). In addition, the Veteran denied other significant medical history or having an illness or injury other than those noted in the entrance RMH. An October 1978 Screening Physical Examination for Army Recruitment (SPEAR Worksheet) indicated that the Veteran did not currently suffer from, or have a history of, fallen arches and that he did not have a history of illness or injury that required repeated treatment by a doctor. In December 1978, an impression of a calcaneal stress fracture was made. An assessment of shin splints was made in June 1979 following the Veteran's complaints of pain down the lower front of both of his legs for two weeks while walking or running. He continued to complain of pain in both legs, along the front and sides of the tibia and from the knee to the ankle, in June 1979, resulting in an assessment of a tendency to pigeon toe deformity. In August 1979, he complained of sharp pains after running for a long period of time; this provider noted that July 1979 X-rays taken to check for pigeon foot syndrome had been negative. The Veteran was assessed with pes varus in October 1979. A referral to the podiatry clinic dated sometime in 1979 indicated that the Veteran had a history of bilateral foot pain with a past history of brace correction for pes varus from age three until age five. A February 1980 Medical Board Proceeding noted the Veteran's report that daily running had resulted in pain in both of his legs and the bottom of his feet and that he had worn braces on both feet from ages three to four due to an in-toeing problem. An accompanying X-ray revealed a bilateral metatarsus adductus. Diagnoses of left leg internal tibial torsion and bilateral metatarsus adductus were made. The Medical Board found that these diagnosed conditions had existed prior to service and were not aggravated by service. An accompanying service discharge examination also noted the left leg internal tibia torsion and bilateral metatarsus adductus. In a July 1980 statement, the Veteran wrote that he was unable to work on his feet for "too long." In a September 2007 Application for Compensation and/or Pension (VA Form 21-526), the Veteran wrote that his Battalion Commander had required him to run every day with boots instead of sneakers. He had been told by the doctor who released him from service that his injuries were the direct result of running without support in his shoes. In an October 2007 statement, the Veteran wrote that he was required to run five to 10 miles per day in combat boots, sometimes with full packs, over a period of eight months during service. He experienced pain and weakness as a result. A May 2009 opinion from Dr. S. P., the Veteran's private podiatrist, noted that the Veteran suffered from chronic pain in his feet and legs. The provider opined that such symptoms, limitations and physical findings were, "for the most part," directly related to the Veteran's time in the service as they were related to overuse injuries in the foot. Such "chronic abuse" during service resulted in plantar heel spurs and posterior calcaneal spurs in the provider's opinion. In addition, the provider noted that the Veteran had no symptoms in his feet or legs prior to service. An accompanying treatment note listed his diagnosis as "no data for diagnosis plantar fasciitis/heel spur syndrome with posterior heel spurs [and] pes valgus." In a May 2009 substantive appeal, the Veteran wrote that his feet were "fine" prior to service as he would not have been accepted into service with "bad" feet. He developed bone spurs and flat feet after running daily for 18 months. During a February 2010 hearing, the Veteran testified that he had disclosed that he was pigeon-toed as a child when he was entering service. He was required to run every day for five miles in full uniform, including boots and packs, during training. He began having symptoms after running in this fashion for about six months. After seeking treatment, he was told he had developed bone spurs and shin splints and was placed on desk duty. A podiatrist later determined that his feet had also gone flat. He subsequently chose to be medically discharged due to the intensity of the ridicule he was receiving as a result of being on desk duty. A September 2010 VA podiatry examination noted the Veteran's reports of wearing a brace from ages one to two due to pigeon toes, which he described as having one foot still inwardly pointed "a little bit but not too much." He indicated that he did not have any other problems until service, when he was required to run five miles per day in full packs and boots. Following service, he worked at a fast food restaurant and reported that he had gained 100 pounds in the first two years after service. Following a physical examination and a review of the Veteran's claims file, the September 2010 VA examiner noted that the diagnosis of bilateral calcaneal bone spurs by the private podiatrist. The examiner, however, found that although the Veteran had a slight drop of the arch on the left, no diagnosis of chronic bilateral pes planus was warranted. The examiner also found that current bilateral metatarsus adductus could not be verified as the Veteran's physical examination did not show abnormal angles in the foot or appreciable tibial torsion of either leg and the angles measured of the feet were equal and within normal limits. The examiner opined that it was therefore not at least as likely as not (less than 50 percent possibility) that the Veteran's bilateral metatarsus adductus and tibia torsion of the left leg were aggravated by service. The examiner further opined that it was less likely than not (less than 50 percent probability) that the Veteran's current bone spurs were occurred in or aggravated by service as his in-service X-rays, conducted 30 years ago, were normal and did not show any bone spurs. The examiner further opined that there were no records related to the Veteran's feet until 2009, that he admitted to having a weight problem and that being on his feet with work for many years and calcaneal bone spurs take "some time" to develop. An April 2012 VA foot Disability Benefits Questionnaire (DBQ) reflected the Veteran's reports of having worn a corrective bar/brace in either preschool or at six years old for a period of six months and that such a brace totally corrected his pigeon toes. He reported working at a fast food restaurant for 120 hours per week, from opening to close, for approximately 14 years after service, although his hours were reduced to part-time after working for seven years. He later stopped working at fast food restaurants due to foot pain and sought more sedentary employment. Following a physical examination and a "careful" review of the Veteran's claims file and medical records, diagnoses of bilateral plantar fasciitis and bilateral calcaneal bone spurs were made. The examiner found that diagnoses of bilateral pes planus and pes varus/valgus were not warranted as such conditions were not found on physical examination and an accompanying X-ray revealed normal alignment of the feet. The examiner also found that a diagnosis related to metatatarsas adductus or tibia torsion of the left leg was not warranted as the Veteran's heel bisector angle and feet as well as tibia alignment were normal on examination and a recent X-ray found normal foot and tibia alignment. The examiner opined that, although the Veteran did have bilateral bone spurs, there was no record of such a condition during service or until 2009, and that this 30 year gap weighed against continuity from active duty to the present. With regards to the Veteran's bilateral plantar fasciitis, the examiner noted that there were no medical evidence documenting his reported foot pain or continued problems for 30 years after service and the medical evidence states that this disorder was caused by the plantar stretching and micro tears of the fascia and was particularly noticeable when changing positions from sitting to standing or from laying down to sitting. In a November 2012 VHA opinion, the examiner opined that it was "less likely or at least as not (50 percent or greater probability)" that the Veteran's diagnosed plantar fasciitis first manifested itself during service or was casually related to service as the wearing of combat boots and undergoing training exercises in the context of having preexisting internal tibial torsion of the left leg and bilateral metatarsus adductus was not related to plantar fasciitis. The examiner noted that he had never seen a patient who had just finished basic training and suffered from plantar fasciitis in his 23 and a half year career as an active duty podiatrist and that this disorder generally was a disease of patients 30 years of age and older. With regard to the Veteran's heel spur, the examiner noted that his in-service foot X-ray was "negative," meaning that there was nothing out of the ordinary, and that in his 31 years of being a podiatrist and taking thousands of X-ray, he did not recall a 20 year old with a heel spur. In addition, the examiner opined that "the finding of a heel spur on X-ray means nothing" as there were patients with large spurs who did not have symptoms of plantar fasciitis and there were patients who had pain without heal spurs. The examiner noted that the words "plantar fasciitis" and "heel spur" have been used interchangeably to describe the same condition by clinicians but, regardless of terminology, the examiner found that there was no evidence to support that the Veteran had this condition while in service. The examiner found that the in-service X-ray did not mention evidence of a calcaneal stress fracture and the Veteran's reported treatment for this condition (i.e. only one week on crutches) was too short a period of time for it to have healed. The examiner opined that the Veteran's bilateral metatarsus and tibial torsi of the left leg were not aggravated by service beyond the natural progression of the disorders as both of these disorders are caused by bony deformities, which the Veteran was born with, and without a substantial fracture the position of his bones would be unchanged today from where they were while he was in service. Metatarsus adductus is best treated as an infant with serial casting and such treatment is not effective if delayed much past the age of nine months. With regards to tibial torsion, this condition is "always left alone" unless a patient has significant in-toed or out-toed gait as a child. Non-surgical treatments such as twister cables, which are cables attached to a girdle type device at the waist and then attached to shoes to turn the foot out, were almost never used as their ability to change the position of the bone was probably minimal at best. Finally, the examiner noted that he had verified that he had never treated the Veteran and that the Veteran's service had predated his own. B. Bilateral Pes Planus Based on a review of the foregoing evidence, the Board notes that that the Veteran has not manifested bilateral pes planus for any time during or after service, including during the course of the appeal. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the current disability requirement is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim). Central to any claim for service connection is a current diagnosis of the claimed disorder. Absent proof of the existence of the disability being claimed, there can be no valid claim. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Degmitech v. Brown, 104 F.3d 1328 (Fed. Cir. 1997); Brammer v. Derwinski, 3 Vet. App. 223(1992). Pes planus, which is otherwise known as "flatfoot," is defined as a deformed foot in which the position of the bones relative to each other has been altered with lowering of the longitudinal arch. DORLAND'S ILLUSTRATED MEDICAL DICTIONARY, 1267 (27th Ed. 1988). Here, the record includes medical opinions by VA examiners in September 2010 and April 2012 that the Veteran did not manifest pes planus. These opinions were based upon record review, physical examination of the Veteran's feet, and x-ray examination of the Veteran's feet. In addition, the record does not reflect a single medical examiner impression that the Veteran manifests pes planus. On the other hand, the Veteran alleges that he manifests pes planus. Clearly, the Veteran is competent to describe the outward manifestations of his foot structure, to include flatness of the feet. However, the Board places greater probative weight to the opinions of the September 2010 and April 2012 as to whether the Veteran's foot structure meets the medical definition of pes planus, as these examiners possess greater expertise and training than the Veteran in diagnosing foot disorders. As the most persuasive evidence of record is against a current finding of bilateral pes planus, service connection for a bilateral foot disability due to pes planus cannot be granted. C. Metatarsus Adductus and Left Leg Internal Tibial Torsion With regards to the Veteran's metatarsus adductus and left leg internal tibial torsion, the Board notes that the September 2010 and April 2012 VA examiners found that such a diagnosis was not warranted based on their findings on physical examination. However, as the November 2012 VHA examiner appears to suggest the presence of these disorders, the Board will consider the requirement of a current disability to have been satisfied. See McClain, supra. The Board finds that the record contains clear and unmistakable evidence that the Veteran's metatarsus adductus and left leg internal tibial torsion preexisted his service. 38 U.S.C.A. § 1111; Wagner, supra. Although these disorders were not noted on the Veteran's service entrance examination, the Veteran testified during his February 2010 hearing that he had disclosed that he was pigeon-toed as a child at service entrance. Service treatment records reflect the Veteran's reports that he had worn a brace to correct pes varus and/or pigeon toes as a child, which he had variously identified as having occurred sometime between the ages of three and five. A February 1980 Medical Board Proceeding determined that these disorders preexisted the Veteran's service based, at least in part, on the Veteran's own reports. Post-service, the Veteran has consistently reported wearing a brace to correct being pigeon-toed as a child. The November 2012 VHA examiner also noted that metatarsus adductus and left leg internal tibial torsion were bone deformities which an individual was born with. The Board observes there is no absolute rule in statute or regulation which requires contemporaneous clinical evidence or recorded history to rebut presumption of soundness, and that presumption of soundness may be overcome by later medical opinion based upon statements made by the veteran about the pre-service history of his condition. Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000). Here, the Board finds that the November 2012 VA examiner provided an opinion of pre-existence based upon review of the entire claims folder, including an accurate recitation of the Veteran's pre-service medical history, and medically described metatarsus adductus and left leg internal tibial torsion as bone deformities which are congenital in nature. On the entirety of the record, the Board finds that the Veteran's metatarsus adductus and left leg internal tibial torsion disabilities clearly and unmistakably existed prior to service. To the extent the Veteran argues otherwise, the Board places greater probative weight to the opinion of the November 2012 VHA examiner as this examiner possesses greater expertise and training than the Veteran in diagnosing foot disorders. Turning to the next question of whether the evidence of record shows that the Veteran's preexisting metatarsus adductus and left leg internal tibial torsion were aggravated (permanently worsened) by his service, the November 2012 VHA examiner found it was "undebatable" that these disorders were not aggravated by service. Specifically, the examiner noted that, absent a substantial fracture, the position of these bones would be unchanged today from where they were during service; the Board notes that there is no evidence in the record which suggests that the Veteran has sustained such a fracture. In addition, a February 1980 Medical Board Proceedings determined that these disorders were not aggravated by service. Notably, the September 2010 and April 2012 VA examiners found that current examination did not warrant diagnoses of metatarsus adductus and left leg internal tibial torsion. The debate as to whether a current metatarsus adductus and left leg internal tibial torsion exists at all lends support to a finding that such disorders were not permanently aggravated during active service. The Board further notes that congenital or development defects may not be service-connected as they are not deemed "diseases" or "injuries" for VA compensation purposes. 38 C.F.R. § 3.303(c). VA's General Counsel has noted that the term "disease" as used in 38 U.S.C.A. §§ 1110 and 1131 and the term "defect" as used in 38 C.F.R. § 3.303(c) are mutually exclusive, so that service connection may be granted for diseases, but not defects, of a congenital, developmental, or familial origin. VAOPGCPREC 82-90 (July 18, 1990). Compensation is payable, however, for injury superimposed upon a congenital defect. Id. As the November 2012 VHA examiner offered opinion that the Veteran's metatarsus adductus and left leg internal tibial torsion were bone deformities which are congenital in nature, the Board is required to determine whether any superimposed injury occurred. Notably, the VHA examiner referred to x-ray finding to determine that the Veteran did not suffer a calcaneal stress fracture, and determined that the Veteran's history of metatarsus adductus and left leg internal tibial torsion in the context of wearing combat foots did not cause plantar fasciitis. The examiner also discussed the significance of calf pain and cramping as well as shin splints. Overall, the Board finds that the VHA examiner addressed the issue of potential superimposed injury. The Veteran has generally alleged that his bilateral foot disability became symptomatic during active service. To the extent that he alleges that his metatarsus adductus and left leg internal tibial torsion were aggravated during active service beyond the normal progress of the disorder, the Board places greater probative weight to the opinion of the November 2012 VHA examiner as this examiner possesses greater expertise and training than the Veteran in diagnosing foot disorders. Notably, the Veteran has also reported being told by a military examiner that his foot disabilities were the direct result of running without support in shoes. The Veteran is clearly competent to relay the contents of a conversation with a physician. However, the Board has no evidence before it to determine the exact diagnosis provided by this examiner or the rationale supporting the opinion provided. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that a medical opinion does not hold probative value when it fails to provide sufficient detail and rationale to allow the Board to make a fully informed evaluation of the disability). Thus, this recollected opinion holds little probative weight when compared to the opinion of the November 2012 VHA examiner. D. Bone/Heel Spurs, Plantar Fasciitis and Pes Varus/Valgus With regards to the Veteran's diagnosed bone or heel spurs, plantar fasciitis and pes valgus, the evidence of record does show a current diagnosis for each disorder. However, the probative evidence of record demonstrates that such disorders did not manifest in service or are not shown to be related to the Veteran's service. The November 2012 VHA examiner determined that the Veteran's plantar fasciitis and heel spurs were less likely than not related to service as such disorders were generally present in patients 30 years of age or older and were the result of the accumulation, over time, of tears at the cellular level. The September 2010 VA examiner determined that the Veteran's bone spurs were less likely than not occurred in or aggravated by service as such a disorder takes time to develop and there was no documentation of such a disorder until many years after service. This examiner specifically explained that x-ray examination in service was reported as negative, which meant that there were no findings out of the ordinary. This examiner also offered opinion that the Veteran's pain complaints could have been attributable to shin splints, which was a self-limiting problem which healed on its own. The Board finds that this opinion is based on an accurate review of the factual history as found by the Board, and provides an opinion which is supported by clearly explained rationale. An April 2012 VA examiner opined that it was less likely that not the Veteran's plantar fasciitis was related to service and cited to the absence of medical documentation of foot pain following service. The extent of foot pain experienced by the Veteran before, during and after service is not clearly defined by the Veteran himself although he generally alleges an increased severity during service. This opinion holds some probative value which is limited by a discussion of the significance of the Veteran's reported pain complaints. In contrast, the Veteran's private podiatrist opined in a May 2009 opinion that the Veteran's plantar heel spurs and posterior calcaneal spurs were "for the most part" related to service and that the Veteran did not have symptoms in his feet or legs prior to service. However, this opinion was not stated to the degree of certainty required to substantiate a claim for service connection and was not accompanied by a rationale. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are speculative, general, or inconclusive in nature cannot support a claim). In addition, this opinion appears to be based on an inaccurate factual premise, namely that the Veteran did not have any feet or leg symptoms prior to service. As discussed above, the Veteran's own statements indicate that he wore a brace to correct being pigeon-toed as a child. See Reonal v. Brown, 5 Vet. App. 460, 461(1993) (an opinion based on an inaccurate factual premise has no probative value). The Board also notes that this provider offered no etiological opinion as to the Veteran's plantar fasciitis. Thus, by comparison, the Board finds that the November 2012 VHA opinion holds substantially greater weight than the May 2002 private podiatry opinion. With regards to the Veteran's pes valgus, the Board notes that the April 2012 VA examiner determined that no such diagnosis was warranted based on the current physical findings and therefore offered no etiological opinion as to this disorder. The May 2009 opinion from the Veteran's private podiatrist similarly offered no etiological opinion regarding this disorder. There is otherwise no probative medical opinion of record which links the Veteran's pes valgus to his service. The Board notes that the Veteran has contended on his own behalf that his current foot disorders are related to his service. He reports being diagnosed with bone spurs and shin splints during active service, and recalls a military examiner advising him that his foot injuries were a direct result of running without support in his shoes. Again, the Veteran is clearly competent to relay the contents of a conversation with a physician involving diagnosis and opinion. However, the Board has no evidence before it to determine the exact diagnosis provided by this examiner or the rationale supporting the opinion provided. See Stefl, 21 Vet. App. 120 (2007). The November 2012 VHA physician specifically found that such disorders were not incurred in service by review of the STRs, including x-ray examination. Overall, the Veteran's recollected diagnosis and opinion holds little probative weight when compared to the opinion of the November 2012 VHA examiner. The Board further observes that the Veteran has provided statements and testimony describing the nature and severity of his bilateral foot symptoms before, during and after service. At the very least, the Veteran appears to report an increased severity of bilateral foot symptoms in service, if not the onset of bilateral foot symptoms in service. The Board does not doubt that the Veteran experienced symptomatic feet during active service, as it is well documented in the record and there is no reason to doubt the credibility of the Veteran. However, the Board has no competence to determine the medical significance of his pain symptoms. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (VA may only consider independent medical evidence to support its findings and is not permitted to base decisions on its own unsubstantiated medical conclusions); Davis, 276 F. 3d at 1346-47 (Fed. Cir. 2002) (noting that intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence aggravation unless the underlying condition worsened). Here, the VHA examiner has directly considered the significance of the Veteran's pain complaints. In particular, the VHA examiner was advised by the Board in the September 2012 VHA opinion request to consider the significance of the Veteran's report of chronic foot pain since service as well as the etiology for recurrent posterior calf cramping. The VHA examiner's opinion on this matter greatly outweighs any probative value regarding the Veteran's own interpretation of the significance of the chronicity and continuity of foot symptoms since service. As a final matter, the Board notes that there is no evidence of arthritis of the feet inservice or within one year from separation from service. Thus, the presumptive provisions of 38 C.F.R. § 3.309(a) do not apply. 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 bilateral foot disorder, to include bilateral pes planus, pes varus/valgus, plantar fasciitis and bilateral calcaneal bone spurs. 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 a bilateral foot disorder, to include bilateral pes planus, pes varus/valgus, plantar fasciitis and bilateral calcaneal bone spurs, is denied. ____________________________________________ T. MAINELLI Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs