Citation Nr: 1311229 Decision Date: 04/04/13 Archive Date: 04/19/13 DOCKET NO. 03-26 933 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for bilateral hearing loss disability. 2. Entitlement to service connection for a left ankle disability. 3. Entitlement to service connection for bilateral foot (other than the ankles) disability. 4. Entitlement to service connection for diabetes mellitus, to include as due to herbicide exposure. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Appellant, J.P., and T.W. ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from August 1972 to July 1975, and unverified periods of National Guard service prior to 1992. These matters come before the Board of Veterans' Appeals (Board) from a January 2002 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in North Little Rock, Arkansas. In December 2003, the Veteran and witnesses testified at a videoconference hearing before a Veterans Law Judge. A transcript of that hearing is of record. These matters were previously before the Board in May 2004, June 2006, April 2008, January 2011, and June 2012, and were remanded for further development. They have now returned to the Board for further appellate consideration. The issue of entitlement to an earlier effective date for the award of service connection for a right ankle disability has been raised by the record (See October 2008 Veteran's statement), but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and it is referred to the AOJ for appropriate action. The issues of entitlement to service connection for a bilateral foot (other than the ankles) disability, entitlement to service connection for a left ankle disability, and entitlement to service connection for diabetes mellitus are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. There has been no demonstration by competent medical evidence, or competent and credible lay evidence, that the Veteran has bilateral hearing loss disability causally related to, or aggravated by, active service. 2. The earliest clinical evidence of bilateral hearing loss disability is more than twenty years after separation from active service. 3. The competent credible evidence of record is against a finding that the Veteran has bilateral hearing loss disability causally related to active service. CONCLUSION OF LAW Bilateral hearing loss disability was not incurred in, or aggravated by, active service, nor may it be presumed (as an organic disease of the nervous system) to have been so incurred or aggravated. 38 U.S.C.A. §§ 1101, 1110, 1112. 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION VA has duties 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). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided to the Veteran in June 2004, June 2006, and June 2008. The above notices did not provide the Veteran with the criteria required to substantiate a claim based upon secondary service connection. Such notice was provided to the Veteran in the December 2012 supplemental statement of the case. VA also has a duty to assist the Veteran in the development of the claim. The claims file contains service treatment records (STRs), VA and private medical records, and the statements of the Veteran and others in support of his claim. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim for which VA has a duty to obtain. The claims file includes a 2012 VA examination and opinion. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the examination and opinion obtained in this case is adequate, as the opinion is predicated on a review of the Veteran's claims file, to include the Veteran's STRs, and clinical examination. It considers the pertinent evidence of record, to include statements of the Veteran regarding his symptoms. Rationale was provided for the opinion proffered. The Board notes that the examiner stated that the recent audiogram found in the claims file was dated January 16, 1988 and reflected normal hearing bilaterally. The Board acknowledges that the examiner did not note more recent audiograms. Nevertheless, such audiograms were more than 20 years after separation from service. Thus, they do not affect the rationale provided by the examiner. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claim. Essentially, all available evidence that could substantiate the claim has been obtained. Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Pursuant to 38 C.F.R. § 3.303(b), a claimant may establish the second and third elements by demonstrating continuity of symptomatology. See Barr v. Nicholson, 21 Vet.App. 303 (2007). Continuity of symptomatology can be demonstrated by showing (1) that a condition was "noted" during service; (2) evidence of continuous symptoms after service; and (3) medical, or in certain circumstances, lay evidence of a nexus between the current disability and the post service symptoms. Savage v. Gober, 10 Vet.App. 488 (1997). See also Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013)(the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic 38 C.F.R. § 3.309(a)). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). Hearing Loss Where a Veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and certain diseases, such as hearing loss disability, as an organic disease of the nervous system, become manifest to a degree of 10 percent or more within one year from the date of termination of such service, such disease(s) shall be presumed to have been incurred in or aggravated by service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309 (2012). For the purposes of applying the laws administered by VA, impaired hearing will be considered to be a disability when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000 and 4,000 Hertz is 40 decibels or greater; or when the thresholds for at least three of these frequencies are 26 decibels or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385 (2012). Where the evidence does not warrant presumptive service connection, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has determined that an appellant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. The Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. The Veteran avers that he has a bilateral hearing loss disability as a result of active service. A July 2012 VA examination report is of record. The report reflects that pure tone thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 30 30 30 35 35 LEFT 30 35 40 40 40 Thus, the Board finds that the Veteran does have a current bilateral hearing loss disability for VA purposes. An essential element of a claim for service connection is medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease. The Veteran's DD 214 reflects that his primary military occupational specialty was as a motor transportation operation (truck driver). The Veteran has stated that he was exposed to loud noises as a truck driver in service. The Board finds that some exposure to acoustic trauma in service as a truck driver is consistent with the circumstances of the Veteran's service. 38 U.S.C.A. § 1154(a) (West 2002). The third requirement for service connection is competent credible evidence of a nexus between the current disability and the in-service disease or injury. The Board finds, for the reasons noted below, that this requirement for service connection has not been met. The Veteran's STRs include a July 1972 report of medical examination for entrance purposes. An audiology evaluation revealed that pure tone air thresholds, in decibels, were as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 5 5 5 -- 5 LEFT 5 5 5 -- 5 In Hensley v. Brown, 5 Vet. App. 155, 157 (1993) the Court held that the threshold for normal hearing is from 0 to 20 decibels, and higher threshold levels indicate some degree of hearing loss. Therefore, the Veteran's entrance examination report reflects normal hearing in both ears. The Veteran May 1975 report of medical history for separation purposes reflects that he denied any hearing loss. The May 1975 report of medical examination for separation purposes includes an audiology evaluation. It revealed that the Veteran's hearing acuity was normal with pure tone air thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 10 10 0 -- 5 LEFT 20 10 10 -- 10 The medical examination report also reflects that the Veteran's ears were normal upon clinical examination. A January 1984 report of medical history, more than eight years after separation from active service, reflects that the Veteran denied any hearing loss. The report of medical examination for National Guard enlistment purposes reflects that the Veteran's hearing acuity was normal with pure tone air thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 10 5 5 0 LEFT 15 10 5 5 10 A January 1988 report of medical history reflects that the Veteran denied hearing loss. The report of medical examination for annual purposes reflects that the Veteran's hearing acuity was normal with pure tone air thresholds, in decibels, as follows: HERTZ 500 1000 2000 3000 4000 RIGHT 20 10 10 10 10 LEFT 20 10 10 10 20 The Board finds that any statement by the Veteran that he had hearing loss in active service or within a year of separation from active service is less than credible when considered with the record as a whole. Not only did the Veteran deny hearing loss in 1975, 1984, and 1988, but the clinical evidence in 1975, 1984, and 1988 reflected normal hearing. The earliest clinical evidence of hearing loss in the left ear is in 1996, more than 20 years after separation from active service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). A May 1996 clinical record reflects normal hearing in the right ("O") ear and mild hearing loss at the 4,000 Hertz level in the left ("X") ear. A May 1997 clinical record reflects normal hearing in the right ear and mild hearing loss at the 4,000 Hertz level in the left ear. A May 1998 clinical record reflects normal hearing in the right ear and mild hearing loss at the 500 Hertz and 4,000 Hertz levels in the left ear. The earliest clinical evidence of hearing loss in the right ear is more than 23 years after separation from active service. The claims file includes an August 2001 VA clinical record. It reflects the Veteran presented with complaints of fair hearing in the right ear and poor hearing in the left ear. It was noted that the "Veteran believes the problem started in 1977, two years after leaving active duty. At the time the problem was noticed he may have been in the Army Reserves. In the Army he worked in Transportation as a heavy truck driver." It also notes that he had at least one noise hazardous job after the military, working in a laundry facility for twenty years. A September 2002 record reflects abnormal hearing in both ears. The claims file includes a July 2012 VA examination report. It reflects the opinion of the examiner that it is not at least as likely as not that the Veteran's current hearing loss disability was caused by or a result of service. As noted above, the examiner noted that the recent audiogram found in the claims file was dated January 16, 1988 and reflected normal hearing bilaterally. The examiner opined that since the Veteran's hearing was within normal limits more than 10 years after he left service, it is not likely his current hearing loss is due to his military experience. The Board acknowledges that the examiner did not note some audio graphs after 1988. Nevertheless, such audio graphs were more than 20 years after separation from service. Thus, they do not affect the rationale provided by the examiner. The Board also acknowledges that VA regulations do not necessarily preclude service connection for hearing loss that first met the 38 C.F.R. § 3.385 requirements after service. Hensley v. Brown, 5 Vet. App. 155, 157 (1993). However, in the present claim, there is no competent clinical opinion, or credible continuity of symptomatology, which supports a causal relationship between the Veteran's current hearing loss disability and active service. While the regulation does not necessarily preclude service connection when hearing loss first meets the regulation's requirements after service, it also does not hold that service connection is warranted, or mandatory, for hearing loss disability in the absence of a competent credible clinical nexus opinion or credible continuity of symptomatology. The Veteran testified at the December 2003 Board hearing the he drove tractor-trailers in service without adequate hearing protection. A witness, J.P., testified that he (the witness), is service-connected for his hearing loss disability and that when the Veteran drove trucks in the 1970s, he did not use hearing protection. He further testified that he and the Veteran had essentially the same duties and drove the same trucks in service. The Board finds that the testimony of J.P. is not sufficient to warrant service-connection for the Veteran. While J.P. and the Veteran may both have driven trucks in service, there is no evidence that J.P. is competent to provide an etiology opinion as to the Veteran's hearing loss disability. The Veteran has been shown to have had normal hearing 10 years after separation from active service, and a clinician, trained in audiology, is more competent to provide an etiology opinion than the Veteran's lay witness. The Board notes that the Veteran is competent to attest to factual matters of which he has first-hand knowledge (e.g., hearing difficulty). See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). To this extent, the Board finds that the Veteran is competent to report that he has current hearing loss. The Board notes that there is no clinical evidence that he complained of, or sought treatment for, hearing loss for more than two decades after separation from service. While the Board acknowledges that the absence of any corroborating medical evidence supporting assertions, in and of itself, does not render lay statements incredible, such absence is for consideration in determining credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that the absence of contemporaneous medical documentation may go to the credibility and weight of Veteran's lay testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible). See also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (noting that lay evidence can be competent to establish a diagnosis when . . . a layperson is competent to identify the medical condition.) In the present claim, not only is there an absence of clinical records supporting any continuity of symptoms from service, but the Veteran previously denied any hearing loss, and the clinical audiograms are against a finding of hearing loss in 1975, 1984, and 1988. The Board also notes that the Veteran had some National Guard service up until June 1991. However, there is no competent credible evidence that he has a current hearing loss disability causally related to any acoustic trauma during such service. In this regard, the Board notes that the earliest clinical evidence of hearing loss in the left ear is in 1996, five years after the conclusion of any National Guard service, and that his right ear was normal at that time. (The record does not reflect that National Guard service was in a federal capacity.) The Veteran has not been shown to have the experience, training, or education necessary to provide a competent opinion as to the etiology of his current hearing loss disability. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issue in this case, hearing loss, more so in the one ear than the other, with a history of truck driving in service, and civilian employment as a machine operator. The Board finds that such an etiology finding falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to service connection for bilateral hearing loss disability is denied. REMAND Left ankle disability A March 2005 VA radiograph record reflects calcaneal spurring and talonavicular spurring. A 2012 VA examination report reflects that the Veteran did not have a current left ankle disability and noted that a 2010 orthopedic examination of the left ankle, to include x-rays, was normal. Unfortunately, this 2010 examination report, with x-rays, is not associated with the claims file. In addition, the 2012 VA examiner did not provide a rationale as to the difference in x-ray findings between 2005 and 2010. Initially, the Board has noted that the Veteran alleges that he has had chronic left ankle pain since service. The Veteran's May 1975 report of medical history for separation purposes reflects that he reported foot trouble; however, the physician's summary and elaboration of all pertinent data reflects it was with regard to the right ankle. The May 1975 report of medical examination for separation purposes reflects that the Veteran's lower extremities and feet were normal upon clinical examination. The report is negative for any complaints specific to the left ankle. A June 1983 clinical record reflects that the Veteran sought treatment for an eye injury while playing basketball. The Board finds it notable that the Veteran was playing basketball, a sport involving the lower extremities, after separation from active service. A January 1984 report of medical history, more than eight years after separation from active service, reflects that the Veteran denied any foot trouble, lameness, or bone, joint, or other deformity. The report reflects that the Veteran's usual occupation was as a laundry machine operator. The January 1984 report of medical examination reflects that the Veteran's lower extremities and feet were normal upon clinical examination. A June 1984 National Guard STR reflects that the Veteran sought treatment for a "hurt ankle". Upon examination, the left ankle was essentially within normal limits. The examiner noted that there was subjective pain on palpation of the lateral aspect of the distal fibula. The impression was mild strain. The Veteran was put on "light duty." A January 1986 record reflects that the Veteran reported playing basketball when he fell and someone landed on the side of his knee. Again, the Board finds it significant that the Veteran was playing basketball. A January 1988 report of medical history for annual purposes reflects that the Veteran denied any foot trouble, lameness or bone, joint, or other deformity. The report of medical examination reflects that the Veteran's lower extremities and feet were normal upon clinical examination. Thus, the report is indicative that any symptoms with regard to the ankle in 1984 no longer present in 1988. A March 1988 emergency room clinical record reflects that the Veteran had a complaint of an injury to his left ankle. It was noted that he reported that he had injured in while chasing a ball. The Veteran was discharged in a wheelchair. A radiograph record reflects as follows: . . .The patient's lateral mortise margin continues to be widened with continued diffuse soft tissue swelling. The articulations of the forefoot and foot proper appear normal. Irregularity at the dorsal aspect of the talus and anterior aspect of the distal tibia are felt to represent degenerative changes in the mortise, unrelated to the present acute trauma. No definite bone fragments are seen. The subtalar joint appears within the range of normal. A June 1988 clinical record reflects that the Veteran was seen for a follow up of the left subtalar. It was noted that he was "doing well" and had complaints of some stiffness after prolonged sitting. Upon examination, the ankle was stable. He had full ankle motion. He had mild swelling. A June 1998 private clinical record reflects that the Veteran reported that he had a history of ankle swelling due to standing on a concrete floor at work every day. He also reported arthritis in the ankles. The Board has considered the lay statements of record, but finds that any statement by the Veteran, and others, that he has had an left ankle pain or symptoms continuously or chronically since service is less than credible when considered with the record as a whole. The Veteran has stated that he has had pain since basic training. The Veteran completed basic training in 1972. In 1975, he complained of right ankle pain, but there is no notation as to left ankle pain. The Board finds that if the Veteran had left ankle pain in 1975, it would have been likely for him to have reported it, and for it to have been noted, when he complained of right ankle pain; it is not. In addition, the Veteran, who separated from active service in 1975, subsequently enlisted in the National Guard. If the Veteran had had chronic left ankle pain since basic training, the Board finds that it would have been unlikely for him to enlist in the National Guard and remain in the Guard for seven years. The Board also notes that the Veteran denied problems in January 1988; thus indicating that his injury in 1984 was acute and transitory. The Board also finds it noteworthy that the Veteran played basketball, or ball, in 1983, 1986, and 1988. The Board finds that if the Veteran had chronic left ankle pain since service, it would have been reasonable for him to have avoided playing basketball. Finally, the Board notes that a June 1998 private clinical record reflects that the Veteran sought treatment for his feet. He reported that he had a history of ankle swelling due to standing on a concrete floor at work every day. The Board finds that if the Veteran had had chronic left ankle pain since service, it would not be reasonable for him to have a job which required excessive standing, and to not to have sought treatment, and have treatment records, for such. In addition, it would not have been reasonable for him to have failed to mention a long history of ankle pain due to service, and instead, to have reported that his pain was due to post service standing at work. Despite the Board's finding that the Veteran is less than credible with regard to continuity of symptoms of a chronic left ankle pain since service, a clinical opinion is still warranted as to whether the Veteran has a current left ankle disability due to service, to include wearing boots. The Veteran has also stated that he has a left ankle disability secondary to his right ankle disability; thus, VA should provide him with notice as to criteria for the award of service connection on a secondary basis. In addition, the VA clinician should provide an opinion with regard to the likelihood of a left ankle disability due to a right ankle disability. Diabetes mellitus The Veteran has provided several theories as to the etiology of his current diabetes mellitus. His contentions are that it is due to herbicide exposure in service, the food he ate in service, and that it was a preexisting disability which was aggravated by active service. Herbicide exposure The Veteran's DD 214 does not reflect service in Vietnam. Moreover, the Veteran has not contended that he served in Vietnam. The Veteran has stated that, while in service, he was involved in taking trunks off of trains, and replacing torn canvas on the trucks. He contends that these trucks were coming from Vietnam. He contends that the canvas on the trucks had an oily or greasy looking substance, and that substance could have been Agent Orange. There is no competent credible evidence of record that the Veteran was exposed to herbicides while on active service. The Board finds that any such statement by the Veteran that he was exposed to herbicides from vehicles is purely speculative and is not competent evidence of exposure. In addition, herbicide exposure from handling vehicles returning from Vietnam is not presumed under VA policy. Pre-existing and aggravation The Veteran also contends that he had diabetes prior to service, and that it was aggravated by active service. The Veteran was diagnosed with diabetes in 1998. A March 1998 clinical record reflects that the Veteran has a family history of diabetes. Another March 1998 Observation Status clinical record reflects that the Veteran had a family history positive for diabetes in the family. It was noted that the positive history was his mother. Thus, as early as 1998, the Veteran was aware that he had a family history of diabetes. Despite this knowledge, the Veteran testified at the December 2003 Board hearing that he did not know of any history of diabetes in his family. (See Board hearing transcript page 12.) He further indicated that it was this lack of family history, which led him to believe that his diabetes was due to herbicide exposure. The Board finds that the Veteran's denial of a family history of diabetes was made in an effort to obtain VA compensation; thus, he lacks credibility. In a statement received by VA in December 2006, the Veteran stated that he did not live with his parents as a child, but rather lived with his grandmother. He further stated that after doing research, "the evidence will show that both parents had diabetes. Research will show that a child with both parents positive with diabetes will have over a 60 percent chance of inheriting the disease. If this is the case, then my diabetes. My diabetes could have been preexisting before I committed to the military in 1972-1991 and could have been aggravated during that period of time." The claims file also includes statements by the Veteran that both his mother and father had diabetes. A March 1997 death certificate, presumably for the Veteran's father, reflects that he had diabetes mellitus. A September 2005 handwritten note, presumably for the Veteran's mother, reflects that she was being treated for Type 2 diabetes. The Veteran's July 1972 report of medical examination for entrance purposes reflects that his endocrine system was normal. A urinalysis was negative for sugar. His report of medical history for entrance purposes reflects that the Veteran denied any sugar in his urine, or any other symptoms indicative of possible diabetes. The Veteran's May 1975 report of medical history for separation purposes also reflects that he denied any sugar in the urine or any other symptoms indicate of possible diabetes. His report of medical examination for separation purposes reflects that the Veteran's endocrine system was normal. His urinalysis was negative for sugar in the urine. In addition, records for the Veteran reflect "adult onset diabetes". The Veteran's January 1984 report of medical examination for annual purposes reflects that his endocrine system was normal. A urinalysis was negative for sugar. His report of medical history reflects that the Veteran denied any sugar in his urine, or any other symptoms indicative of possible diabetes. The Veteran's January 1988 report of medical examination for annual purposes reflects that his endocrine system was normal. A urinalysis was negative for sugar. His report of medical history reflects that the Veteran denied any sugar in his urine, or any other symptoms indicative of possible diabetes. The earliest clinical evidence of symptoms is in 1998. A March 1998 clinical record reflects that the Veteran had "no significant past medical history, but in 3-4 months complained of progressive fatigue, blurred vision, weight loss of around 15 pounds, polydipsia, polyuria, intermittent paresthesias of the fingers with decreased sensation of bilateral lower and upper extremities. The patient states he read these type of symptoms in a book and feels that he might have had diabetes." Thus, the record reflects that the Veteran's symptoms of diabetes mellitus had their onset in late 1997 or early 1998, more than twenty years after separation from active service. There is no competent credible evidence that he had manifestations prior to service, in service, or within one year after separation from active service; the Board finds that he did not have preexisting diabetes mellitus. He is presumed to have been sound, with regard to his endocrine system, upon entrance. 38 U.S.C.A. § 1111 (West 2002). See also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). Diet in service The Veteran contends that his diabetes is due to eating food high in cholesterol and preservatives in service. The 2012 VA examiner noted that "there is no evidence of diagnosis or treatment of diabetes in the service." The examiner failed to state whether it is as likely as not (50 percent or greater) that the Veteran's current diabetes is causally related to active service, to include his diet. The Board is mindful that the Veteran did not have a diagnosis of diabetes in service, but an opinion as to whether it is likely that his current diabetes, diagnosed many years after separation from service, is related to service, is still warranted. Stegall v. West, 11 Vet. App. 268 (1998) Based on the foregoing, a supplemental clinical opinion is warranted. Bilateral foot disability In its June 2012 remand, the Board directed that the Veteran be afforded a VA examination with regard to his left foot. Unfortunately, the Board failed to have the examiner address the Veteran's right foot. In addition, the Board finds that a more thorough rationale may be helpful to the Board in adjudicating the Veteran's claim. In this regard, the examiner should discuss, if pertinent, the Veteran's STRs, his military occupational specialty as a truck driver, his post-service years of working on a concrete floor (See April 1998 clinical record which reflects that the Veteran was employed full time "on feet", and June 1998 private clinical record which reflects his employed included standing on a concrete floor at work every day), his civilian treatment records, the length of time between separation from service and a bilateral foot disability diagnosis, and the March 1998 record by Dr. A.B. which states that the "formation of calluses on the plantar aspect of the patient's feet is a chronic condition secondary to underlying bony deformity, and his diagnoses of Morton's foot configuration, clawing toes, calluses. The Veteran's May 1975 report of medical examination for separation purposes reflects that the Veteran's lower extremities and feet were normal upon clinical examination. A January 1984 report of medical history, more than eight years after separation from active service, reflects that the Veteran denied any foot trouble, lameness, or bone, joint, or other deformity. The report reflects that the Veteran's usual occupation was as a laundry machine operator. The January 1984 report of medical examination reflects that the Veteran's lower extremities and feet were normal upon clinical examination. A January 1988 report of medical history for annual purposes reflects that the Veteran denied any foot trouble, lameness or bone, joint, or other deformity. The report of medical examination reflects that the Veteran's lower extremities and feet were normal upon clinical examination. An April 1998 clinical record reflects that the Veteran had numbness in his feet and a callus on the left foot that was painful. It was noted that he was employed full time "on feet". A June 1998 private clinical record reflects that the Veteran sought treatment for his feet. He reported that he had a history of ankle swelling due to standing on a concrete floor at work every day. He also reported arthritis in the ankles. The Board finds that the Veteran's statements as to chronic foot trouble in service are less than credible in that they are contradicted by his service treatment records and previous denials of such. Nevertheless, a clinical opinion as to whether he has a current foot disability causally related to active service is still warranted. Accordingly, the case is REMANDED for the following action: 1. Issue a VCAA notice letter for the issue of entitlement to a left ankle disability as secondary to a service-connected disability in accordance with 38 U.S.C.A. §§ 5102, 5103, and 5103A (West 2002), 38 C.F.R. § 3.159 (2009), Quartuccio v. Principi, 16 Vet. App. 183 (2002), Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), and any other applicable legal precedent. 2. Attempt to obtain a 2010 orthopedic examination records of the left ankle, to include x-ray findings (cited by the 2012 VA examiner). Associate all obtained records with the claims file. 3. Thereafter, obtain a supplemental opinion as to whether it is as likely as not (50 percent or greater) that the Veteran has a current left ankle disability causally related to, or aggravated by, active service, or related to, or aggravated by a service connected disability, to include the right ankle. The examiner should provide a complete rationale as to any opinion offered. Any such rationale should consider, if pertinent, 1) the March 2005 VA radiograph record which reflects calcaneal spurring and talonavicular spurring. 2) 2010 x-rays, if available, 3) the Veteran's STRS (to include May 1975 active service record and National Guard records from January 1984, June 1984, and January 1988), 4) a March 1988 emergency room clinical record reflects which notes a irregularity at the dorsal aspect of the talus and anterior aspect of the distal tibia, 5) a June 1998 private clinical record which reflects that the Veteran had a history of ankle swelling due to standing on a concrete floor at work every day and arthritis in the ankles. 4. Obtain a supplemental opinion as to whether it is as likely as not (50 percent or greater) that the Veteran's diabetes is causally related to, or aggravated by, active service. The evidence does not support a finding that the Veteran was exposed to herbicides or that he had diabetes prior to service; thus, those two factors are not for consideration by the examiner. The examiner should provide a complete rationale as to any opinion offered. Any such rationale should consider, if pertinent, 1) the Veteran's family history of diabetes, 2) his STRs, 3) the onset date of the Veteran's diabetes, and 4) the Veteran's allegations that he ate a diet high in cholesterol and preservations while in service. The claims folder should be reviewed in conjunction with such examination and the examination report should indicate that such a review was performed. 5. Obtain a supplemental opinion as to whether it is as likely as not (50 percent or greater) that the Veteran has a bilateral foot disability (other than the ankles) causally related to, or aggravated by, active service. The examiner should consider the entire claims file. The examiner should provide a complete rationale as to any opinion offered. Any such rationale should consider, if pertinent, 1) the Veteran's STRs, 2) his military occupational specialty as a truck driver and his reports of wearing combat boots, 3) his post-service years of working on a concrete floor (See April 1998 clinical record which reflects that the Veteran was employed full time "on feet", and June 1998 private clinical record which reflects his employed included standing on a concrete floor at work every day), 4) his civilian treatment records, 5) the length of time between separation from service and a bilateral foot disability diagnosis, 6) the March 1998 record by Dr. A.B. which states that the "formation of calluses on the plantar aspect of the patient's feet is a chronic condition secondary to underlying bony deformity", and 7) the prior clinical findings, to include, Morton's foot configuration and clawing toes (April 2007 VA record), calluses, and diabetes. The claims folder should be reviewed in conjunction with such examination and the examination report should indicate that such a review was performed. If the clinician cannot render a competent opinion without an examination, the Veteran should be scheduled for one. 6. After undertaking any other development deemed appropriate, the RO should readjudicate the issues on appeal. If any benefit sought on appeal is not granted, the RO should issue a supplemental statement of the case and provide the Veteran and his representative with an appropriate opportunity to respond. The case should then be returned to the Board for further appellate consideration. The appellant has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs