Citation Nr: 1311275 Decision Date: 04/05/13 Archive Date: 04/19/13 DOCKET NO. 08-26 080 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for disorders of the muscles and joints, including gout and arthritis. 2. Entitlement to service connection for hypertension, to include as secondary to service-connected posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for a headache disorder, to include as secondary to PTSD. 4. Entitlement to service connection for depression, to include as secondary to PTSD. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J.M. Rutkin, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1967 to May 1969, including service in Vietnam. He is the recipient of the Silver Star and Combat Infantryman Badge, among other citations. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran testified at a December 2012 hearing before the undersigned. A transcript of the hearing is in the file. Additional evidence has been associated with the file since this claim was last adjudicated by the RO in a July 2011 Supplemental Statement of the Case (SSOC). Under 38 C.F.R. § 20.1304(c) (2012), any pertinent evidence accepted directly at the Board must be referred to the RO as the agency of original jurisdiction (AOJ) for initial review unless this procedural right is waived by the appellant. The additional evidence consists of VA examination reports unrelated to the claims currently before the Board, and VA treatment records and treatise evidence submitted by the Veteran accompanied by a December 2012 statement waiving his right to initial consideration of this evidence by the RO/AOJ. The Veteran also stated at the December 2012 Board hearing that he waived his right to initial consideration by the RO/AOJ of additional evidence submitted by him on the day of the hearing. Accordingly, the Board may proceed with appellate review. See id. At the December 2012 hearing, the Veteran raised a claim for an increased rating for his service-connected PTSD. This claim has not yet been adjudicated by the RO as the AOJ and is referred to the RO for appropriate action. The Veteran submitted original photographs in support of his claim, and expressed his wish in the August 2008 substantive appeal (VA Form 9) that they be returned to him after a decision had been made on his claim. As the photographs are not relevant to his claims, they should be returned to him as soon as possible. They are located a few pages below his substantive appeal. A review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. The service connection claims for hypertension and a headache disorder 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. The preponderance of the evidence shows that the Veteran's musculoskeletal disorders, including gout and arthritis, were not caused or aggravated by medications taken for his service-connected PTSD and atopic dermatitis. 2. The Veteran served on land in Vietnam during the Vietnam Era, and is presumed to have been exposed to herbicides such as Agent Orange. 3. The competent evidence does not show that the Veteran was exposed to lead, depleted uranium, the chemical components in TNT, or any other chemical or substance alleged to have caused or aggravated gout or arthritis. 4. The preponderance of the evidence shows that the Veteran's musculoskeletal disorders, including gout and arthritis, were not caused or aggravated by exposure to herbicides such as Agent Orange, or by any other disease, injury, or event during active service. 5. The Veteran expressed his wish to withdraw his appeal of the denial of service connection for depression in a December 2012 written statement which bears his name and claim number. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection on a direct, presumptive, or secondary basis for disorders of the muscles and joints, including gout and arthritis, have not been met. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. The criteria for withdrawal of a substantive appeal with regard to service connection for depression have been met. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. § 20.204 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board will discuss the relevant law which it is required to apply. This includes statutes enacted by Congress and published in Title 38, United States Code ("38 U.S.C.A."); regulations promulgated by VA under the law and published in the Title 38 of the Code of Federal Regulations ("38 C.F.R.") and the precedential rulings of the United States Court of Appeals for the Federal Circuit (Federal Circuit) (as noted by citations to "Fed. Cir.") and the United States Court of Appeals for Veterans Claims (Court) (as noted by citations to "Vet. App."). The Board is bound by statute to set forth specifically the issue under appellate consideration and its decision must also include separately stated findings of fact and conclusions of law on all material issues of fact and law presented on the record, and the reasons or bases for those findings and conclusions. 38 U.S.C.A. § 7104(d) (West 2002); see also 38 C.F.R. § 19.7 (2012) (implementing the cited statute); see also Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999); Gilbert v. Derwinski, 1 Vet. App. 49, 56-57 (1990) (the Board's statement of reasons and bases for its findings and conclusions on all material facts and law presented on the record must be sufficient to enable the claimant to understand the precise basis for the Board's decision, as well as to facilitate review of the decision by courts of competent appellate jurisdiction. The Board must also consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts). I. Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000) (codified as amended at 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5107 (West 2002), sets forth VA's duty to notify and assist claimants in substantiating a claim for VA benefits. See 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In order to satisfy its duty to notify the claimant under the VCAA, 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. Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002). All notice under the VCAA should generally be provided prior to an initial 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) (Pelegrini II). However, the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an SOC or SSOC, is sufficient to cure a timing defect. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007); Prickett v. Nicholson, 20 Vet. App. 370 (2006). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484 (2006), the Court held that a claim of entitlement to service connection consists of five elements: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. Notifying the claimant of what evidence is necessary to substantiate the claim under U.S.C.A. § 5103(a), the first notice element in Quartuccio, requires notice of these five elements. See id. at 486; Quartuccio, 16 Vet. App. at 187. Prior to the initial rating decision, a May 2006 letter informed the Veteran of all five elements of direct service connection as well as the elements of service connection on a secondary basis, gave examples of the types of evidence the Veteran could submit in support of his claim, and provided notice of the Veteran's and VA's respective responsibilities for obtaining records and other evidence on his behalf. Therefore, the duty to notify has been satisfied. See id. VA's duty to assist under the VCAA includes helping the claimant to obtain service treatment records and other pertinent records, as well as providing an examination or obtaining a medical opinion when such is necessary to make a decision on the claim. See 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). The Veteran's service treatment records and VA medical records are in the file. Private medical records identified by the Veteran have also been associated with the file to the extent possible. At the December 2012 Board hearing, the Veteran denied receiving disability benefits from the Social Security Administration (SSA). Moreover, when the RO attempted to obtain any SSA records for the Veteran, SSA responded in May 2010 that the records had been destroyed. The RO issued a memorandum for the file in July 2011 making a formal finding of unavailability of any SSA records. The memorandum sets forth the effort made to obtain them and SSA's negative response. Documentation in the file also shows that the Veteran was notified by phone that his SSA records were unavailable. He stated at this time that they were not in his possession. Thus, further efforts to obtain any SSA records for the Veteran would be futile. 38 C.F.R. § 3.156(c)(2) (providing in relevant part that VA will end its efforts to obtain records from a Federal department or agency only if VA concludes that the records do not exist or that further efforts to obtain those would be futile; cases in which VA may conclude that no further efforts are required include those in which the Federal department or agency advises VA that the requested records do not exist). The Veteran has not identified any other outstanding records that he wanted VA to obtain or that he contended were relevant to the present claim. Accordingly, the duty to assist has been satisfied with respect to obtaining relevant records on the Veteran's behalf. See 38 C.F.R. § 3.159(c). The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 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). However, unless the claimant challenges the adequacy of the examination or opinion, the Board may assume that the examination report and opinion are adequate, and need not affirmatively establish the adequacy of the examination report or the competence of the examiner. Sickels v. Shinseki, 643 F.3d, 1362, 1365-66 (Fed. Cir. 2011) (holding that although the Board is required to consider issues independently raised by the evidence of record, the Board is still "entitled to assume" the competency of a VA examiner and the adequacy of a VA opinion without "demonstrating why the medical examiners' reports were competent and sufficiently informed"); see also Rizzo v. Shinseki, 580 F.3d 1288, 1290-1291 (Fed. Cir. 2009) (holding that the Board is entitled to assume the competency of a VA examiner unless the competence is challenged). Id. Here, a VA joints examination was performed in July 2006 and an opinion was provided as to whether the Veteran's muscle and joint pain was due to medications he took for service-connected PTSD or atopic dermatitis. The VA examination report and opinion are adequate for deciding this claim. The examiner reviewed the claims file and medical history, conducted an examination of the Veteran and recorded the clinical findings, and opined that the Veteran's gout, which at the time was the only diagnosis for the Veteran's musculoskeletal pain, was not due to medications he took for PTSD and atopic dermatitis (the examiner did not directly mention atopic dermatitis, but did list a topical cream used to treat atopic dermatitis among the medications that were found not to be related to gout) as they were not known "to increase the incidence of gout." Although the examiner did not use the word "aggravation," it is clear from the phrase "increase the incidence" that the opinion encompassed the issue of aggravation. This is evidenced because the examiner noted that the Veteran reported having symptoms of gout since the 1970's, and thus the only possible relationship between his more recently prescribed medications and gout would be based on aggravation. See Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (holding that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion" even when the rationale does not explicitly "lay out the examiner's journey from the facts to a conclusion" ) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)); see also D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (holding that an examination is adequate when it is based on consideration of the claimant's medical history and describes the disability in sufficient detail so that the Board's evaluation of the disability will be a fully informed one). There are no significant inconsistencies or ambiguities in the examination report, and the claimant has not challenged its adequacy or thoroughness, or the competency of the examiner. See Sickels, 643 F.3d at 1365-66; Rizzo, 580 F.3d at 1290-1291. Further examination or opinion to address the issue of whether the Veteran's medications for his service-connected PTSD and atopic dermatitis caused or aggravated his gout or more recently diagnosed arthritis and tenosynovitis is not warranted. He has not submitted any competent evidence indicating that the medications he has taken for PTSD and atopic dermatitis can cause or aggravate any of these disorders. His lay opinion on this issue, without any supporting explanation or medical evidence, does not constitute competent evidence in support of such a relationship, as this is a medical or scientific determination that is too complex to be made based on lay observation alone. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007)(observing that a layperson can be competent to identify conditions that are simple, such as a broken leg, but is not competent to identify more complex conditions such as a form of cancer); Barr v. Nicholson, 21 Vet. App. 303, 309 (2007) (holding that lay testimony is competent as to matters capable of lay observation, but not with respect to determinations that are "medical in nature"); Layno v. Brown, 6 Vet. App. 465, 469- 71 (1994) (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration, and that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). As there is no indication that the Veteran's gout, arthritis, tenosynovitis, or any other disorder of the musculoskeletal system has been caused or aggravated by medications for PTSD or atopic dermatitis, further opinion on this issue is not warranted. See McLendon, 20 Vet. App. at 83 (holding that there must be an indication that the current disability is related to an in-service disease, injury, or event to trigger the duty to provide an examination or opinion); see also Barr, 21 Vet. App. at 312 (indicating that even if an adequate examination or opinion has not been provided, VA need not provide further examination or opinion if it determines that such is not warranted and provides a sufficient explanation for this determination). The VA examiner was not asked to opine on whether the Veteran's musculoskeletal disorder or gout was caused or aggravated by a disease, injury, or event during active service. In McLendon, 20 Vet. App. at 83, the Court held that there must be an indication that a current disorder may be related to an in-service disease, injury, or event for a claimant to be entitled to a VA examination or opinion. A VA examination or opinion on the issue of direct service connection is not warranted. The Veteran has argued that his gout and musculoskeletal pain was caused or aggravated by in-service exposure to herbicides and other chemicals or substances, including lead, TNT, and depleted uranium. However, as discussed in more detail below, while the Veteran is presumed to have been exposed to herbicides such as Agent Orange, there is no competent evidence of record of an association between such exposure and gout or other musculoskeletal disorders. Further, although there is an article of record indicating that lead exposure can be associated with gout, there is no competent evidence showing that the Veteran had meaningful lead exposure during active service. The only mention of lead exposure associated with firearms in the evidence of record is an article which mentions making bullets or shooting in an indoor firing range as a possible source of such exposure. The Veteran does not state and the evidence does not otherwise show that he made bullets or discharged firearms indoors during service. Significantly, there is no competent evidence suggesting that the use of firearms outdoors, or being in proximity to exploding artillery is a source of lead exposure. Additionally, if there were such evidence as the Veteran being assigned to duties consistent with such experience, the Board does not discern a means by which the amount of such exposure could be quantified. Moreover, there is no competent evidence showing that the Veteran was exposed to any of the other chemicals mentioned in the statements and articles submitted by him, as shown in the discussion below. Thus, as there is no indication of a relationship between the Veteran's musculoskeletal disorders, including gout and arthritis, and chemical exposure during service, a VA examination or opinion is not required on this issue. See id. Further, although the Veteran reported low back pain during service, this pain resolved by the time of separation, objective disease or pathology was not found a the time, and a chronic back disorder during service has not been shown. The Veteran did not have low back pain again until 2005 or over thirty-five years after he separated from active service. Thus, there is no indication that his current low back pain is related to the back pain he had during active service given the long period of time that elapsed and the fact that his back was normal at separation. Therefore, a VA examination or opinion is not warranted on this issue. See id. Finally, while the Veteran stated at the July 2006 VA examination and the December 2012 Board hearing that his gout or musculoskeletal pain has been present since the 1970's, he does not allege that such pain was present during service or in the first few years after service. There is no other indication that joint or muscle pain which developed some years after service is related to the Veteran's active duty in the absence of a relevant disease, injury, or event at the time. Thus, a VA examination on this issue is not warranted. See id. Accordingly, VA's duty to assist with respect to obtaining a VA examination or opinion has been met to the extent warranted under the VCAA. See 38 C.F.R. §§ 3.159(c)(4); 3.326(a); McLendon, 20 Vet. App. at 83; Barr, 21 Vet. App. at 312. In sum, VA's duty to notify and assist under the VCAA has been satisfied. The Veteran has had ample opportunity to participate in the development of his claim. See Arneson v. Shinseki, 24 Vet. App. 379, 389 (2011) (citing Overton v. Nicholson, 20 Vet. App. 427, 435 (2006) (finding that any error depriving a claimant of "a meaningful opportunity to participate effectively in the processing of his or her claim . . . . must be considered prejudicial")). Any defect in the notice or assistance provided did not affect the outcome of this claim or compromise the "essential fairness of the adjudication," and no such defect has been alleged. See Mayfield v. Nicholson, 19 Vet. App. 103, 116 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). Thus, any error in the notice or assistance provided was harmless, and no prejudice exists. See Shinseki v. Sanders 556 U.S. 396, 407, 410 (2009) (holding that the "rule of prejudicial error" requires a case-by-case determination as to whether the error in question was harmless, and that it is the burden of the claimant to show that the error was harmful by at least providing an explanation as to how the error caused harm); see also 38 U.S.C.A. § 7261(b)(2) (West 2002). Accordingly, the Board may proceed with appellate review. III. Procedural Due Process The Veteran testified before the undersigned at a December 2012 Board hearing. Under 38 C.F.R. § 3.103(c)(2) (2012), it is the responsibility of the hearing officer to explain fully the issues and suggest the submission of evidence which the claimant may have overlooked and which would be of advantage to the claimant's position. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that the hearing officer has two distinct duties under section 3.103(c)(2). First, the hearing officer must explain fully the issues still outstanding that are relevant and material to substantiating the claim by explicitly identifying them for the claimant. Id. at 496 (finding that a hearing officer's inquiries regarding the existence of a current disability and a nexus to service did not equate to explaining that these issues were material to substantiating the claim). Second, the hearing officer must suggest that a claimant submit evidence on an issue material to substantiating the claim when such evidence is missing from the record or when the testimony at the hearing raises an issue for which there is no evidence in the record. Id. at 496-97. Importantly, the Court also observed that the rule of prejudicial error applies in assessing any deficiency with respect to the hearing officer's duties under section 3.103(c). See id. at 498. Citing Sanders, 556 U.S. at 407, 410, the Court noted in this regard that the rule of prejudicial error requires a case-by-case determination as to whether the error in question was harmless. Id. Thus, in Bryant, 23 Vet. App. at 498-99, the Court held that although the hearing officer did not explicitly lay out the material issues of medical nexus and current disability with regard to several claims on appeal in that case, the "clarity and completeness of the hearing record was intact" and the purpose of section 3.103(c)(2) fulfilled because the record reflected that these issues were developed by VA, including the provision of a VA medical examination report, and there was no indication that the appellant had any additional information to submit. Therefore, the Court concluded that any deficiencies in the hearing under section 3.103(c)(2) did not prejudice those claims. Id. The outstanding issue here is whether the Veteran's musculoskeletal disorders, including gout and arthritis, were caused or aggravated by medications taken for his service-connected PTSD and atopic dermatitis, by exposure to herbicides during active service, or by exposure to lead, depleted uranium, or the chemical components in TNT. During the hearing, the undersigned informed the Veteran that scientific studies specific to the Veteran's situation and a medical opinion were necessary to help support his contention that his musculoskeletal disorder was caused by chemical exposure. Hearing Transcript, p. 23. The undersigned also asked the Veteran whether a physician had provided a positive nexus opinion on these issues, and invited him to identify and/or submit any outstanding private treatment records or medical opinions. Hearing Transcript, pgs. 17-19. The undersigned also reiterated that it was very important that the Veteran submit any articles and medical opinions supporting his contentions. Hearing Transcript, p. 24. The Veteran did not raise any new issues pertaining to his claim at the hearing. Thus, the duty to inform the Veteran of the outstanding issues relevant and material to the claim (namely competent evidence of a relationship to service or to a service-connected disability), and to suggest the submission of evidence when such evidence is missing or has been overlooked, has been satisfied. See id. at 496-97. The Veteran has not alleged that there were any deficiencies in the Board hearing. See Bryant, 23 Vet. App. at 497-98. Moreover, even assuming that there were such a deficiency, it did not prejudice the Veteran's claim, as it has been fully developed, to include providing a VA examination and making appropriate efforts to obtain records on the Veteran's behalf, as shown in the above discussion with regard to VA's duty to assist under the VCAA. See id. Notably, there is no potentially relevant evidence that remains outstanding as was the case with one of the claims in Bryant. With regard to that claim, the Court found that a "failure to explicitly lay out the material issues . . . was combined with a failure to suggest to the appellant that he should secure and submit medical evidence on the key issue of nexus to service-evidence that was lacking at the time of the hearing, and that remained lacking through final Board decision." Id. at 499. Thus, the Court found prejudicial error under section 3.103(c)(2) with respect to that claim. Id. By contrast, as shown in the above discussion, the undersigned informed the Veteran several times at the Board hearing that it was important he submit a positive nexus opinion from a physician as well as scientific studies or medical articles in support of his claim. The Veteran has in fact submitted numerous articles and studies, as well as a September 2005 private treatment record (among others) in which he apparently asked his physician to provide an opinion in support of his claim (his physician noted in this record that the Veteran was trying to establish a service connection claim). Thus, the "clarity and completeness of the hearing record [is] intact," and the purpose of section 3.103(c)(2) to develop the record in support of the Veteran's claim has been fulfilled. See id.; see also Sanders 556 U.S. at 407, 410; Mayfield, 19 Vet. App. at 122 (holding that an error is not prejudicial when it does not affect the outcome of a claim). There is no indication that the Veteran has any outstanding evidence to submit. Accordingly, the Veteran's right to a Board hearing has been satisfied and no prejudice exists with regard to the hearing officer's duties under section 3.103(c)(2). See id. IV. Service Connection The Board has thoroughly reviewed all the evidence in the claims file, and has an obligation to provide an adequate statement of reasons or bases supporting its decision. See 38 U.S.C.A. § 7104 (West 2002); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Caluza v. Brown, 7 Vet. App. 498, 506 (1995) The standard of proof to be applied in decisions on claims for veterans' benefits is the benefit-of-the-doubt rule set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must weigh against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). The Board must assess the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). This evaluation generally involves a three-step inquiry. First, the Board must determine whether the evidence is competent. See, e.g. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007). Second, the Board must determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). Third, the Board must assess the probative value and weight of the evidence in light of the entire record. Gonzales, 218 F.3d at 1380-81. As observed by the Federal Circuit, lay evidence must "demonstrate some competence." See King v. Shinseki (Fed. Cir. 2012) (citing 38 U.S.C.A. § 5107(b) and 38 C.F.R. § 3.307(b)) (internal quotation marks omitted). The Board may therefore discount the probative value of lay evidence if it finds such evidence not to be competent. See id.; see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (holding that in order for testimony to be probative of any fact, the witness must be competent to testify as to the facts under consideration). However, the Board may not "categorically" require medical evidence or disregard lay evidence without first assessing its competence. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (holding that it was error in a cause-of-death claim to find "categorically" that a medical opinion was required to prove a nexus between the Veteran's service-connected mental disorder and his drowning death, and likewise to reject categorically the claimant's testimony on this issue as not competent simply because she was a lay person); see also Kahana v. Shinseki, 24 Vet. App. 428, 434 (2011) (holding that the Board erred in categorically rejecting lay evidence without analyzing and weighing it). Importantly, lay statements submitted by or on behalf of a claimant can be competent with respect to both the diagnosis and the etiology or cause of a disability. See Davidson, 581 F.3d at 1316. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. See 38 C.F.R. § 3.159(a)(2); Layno, 6 Vet. App. at 469 (holding that lay testimony is not competent to prove that which would require specialized knowledge, training, or medical expertise). Lay evidence is competent if it is provided by a person who has first-hand knowledge of facts or circumstances, or conveys matters that can be observed and described by a lay person. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005) (holding that appellant was competent to testify as to factual matters of which he had first-hand knowledge, such as experiencing pain in his right hip and thigh in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy). For example, the Court has held that a lay person is competent to diagnose a disease with "unique and readily identifiable features" such as varicose veins. Barr v. Nicholson, 21 Vet. App. 303, 309 (2007). Similarly, the Court has found a lay person competent to identify tinnitus and flat feet, which are disorders that can be identified based on lay observation alone. See Charles v. Principi, 16 Vet. App. 370 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398 (1995) (flatfeet). However, lay testimony is not competent with respect to determinations that are "medical in nature" or require medical knowledge due to their complexity. See Barr, 21 Vet. App. at 309. For example, the Court held that a claimant was not competent to determine whether he had rheumatic fever, which was a more medically complex condition. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). The Federal Circuit has held that lay evidence may be competent and sufficient to establish a diagnosis of a condition in the following circumstances: (1) when the condition is simple, such as a broken leg, as opposed to when the condition is more complex, such as a form of cancer; (2) when the layperson is reporting a contemporaneous medical diagnosis, or; (3) when lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F. 3d 1372, 1377 & n4 (Fed. Cir. 2007). Competent medical evidence, as distinguished from lay evidence, is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1). Competent medical evidence may include statements conveying sound medical principles found in medical treatises. Id. It would also include statements contained in authoritative writings such as medical and scientific articles and research reports or analyses. Id. The competency of evidence differs from the weight assigned to the evidence, which varies according to its credibility, probative value, and relationship to other items of evidence. See Layno, 6 Vet. App. at 469 (holding that the weight and credibility of testimony, as distinguished from its competency, is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted); accord Rucker v. Brown, 10 Vet. App. 67, 74 1997); see also Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997) (holding that the Board has the "authority to discount the weight and probity of evidence in the light of its own inherent characteristics in its relationship to other items of evidence"); Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) (stating that "although interest may affect the credibility of testimony, it does not affect competency to testify."). Thus, evidence which the Board finds is not credible also lacks weight. See Washington, 19 Vet. App. at 368 (noting that the witness's credibility affects the weight to be given to his testimony). Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the United States Court of Appeals for the Federal Circuit (Federal Circuit) held that a three-part test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Claims for certain chronic diseases, namely those listed in 38 C.F.R. § 3.309(a), benefit from a somewhat more relaxed evidentiary standard. See Walker, supra. (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases"). Specifically, when a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. § 3.303(b). If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id.; see also Walker, (observing that subsection 3.303(b) provides a "second route by which a veteran can establish service connection for a chronic disease"). When the claim is for a disorder or disease not listed in section 3.309(a), then "the 'nexus' requirement of the three-element test" must be satisfied, and evidence of a continuity of symptomatology will not suffice to establish service connection. Id. (holding that the claimant's allegation of a continuity of hearing loss ever since active service was not sufficient to support the claim under subsection 3.303(b), as hearing loss was not among the chronic diseases listed in section 3.309(a)). The Federal Circuit has clarified that the "medical nexus" requirement of the three-element test is a higher evidentiary showing than the more relaxed continuity-of-symptomatology standard, and that the latter only applies to the specific chronic diseases listed in section 3.309(a) of the regulations. Id. The Veteran has been diagnosed with arthritis of the fingers and shoulders, as shown in November 2010 and April 2011 VA treatment records. Because osteoarthritis is defined as a chronic disease in section 3.309(a), the provisions of subsection 3.303(b) for chronic disabilities apply, and service connection for arthritis may be established by evidence of a continuity of symptomatology after service. However, gout is not among the chronic diseases set forth in section 3.309(a), and thus evidence of a continuity of symptomatology is not sufficient by itself to establish service connection for this disorder. See id. The Veteran's arthritis is also eligible for presumptive service connection. Specifically, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, service connection for osteoarthritis may be established on a presumptive basis by showing that the disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307; 3.309(a). However, this presumption will be rebutted if there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(d). In his April 2006 claim, the Veteran argued that his muscle and joint pain was the result of side effects from medications he took for service-connected PTSD and atopic dermatitis, including Trazodone, Felodipine, Lisinopril, and Sertraline. Service connection may be established on a secondary basis for a disability which is proximately due to, or the result of, a service connected disease or injury. 38 C.F.R. § 3.310(a). The Court has construed this provision as entailing "any additional impairment of earning capacity resulting from an already service connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service connected condition." Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on a secondary basis, the evidence must show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. An October 2005 VA treatment record reflects that the Veteran reported having joint pains for about 20 years, but denied previous treatment for them. However, in a February 2006 VA treatment record, the Veteran reported being diagnosed with some form of gout or arthritis since the 1980's. The VA treatment records show that after a flare-up of pain in his leg and toe, he was diagnosed by rheumatology with "crystal proven" polyarticular gout in February 2006 based on a culture of fluid taken from his knee and other diagnostic testing. Later he was also diagnosed at VA with arthritis of the fingers and shoulders, as shown in March 2008, November 2010 and April 2011 VA treatment records, and rotator cuff disease and tendonitis of the shoulder, as shown in a February 2007 VA treatment record. A September 2005 private treatment record also shows a diagnosis of arthritis. At the July 2006 VA examination, the Veteran reported that his gout had its onset in the 1970's. After reviewing the Veteran's medical records and examining him, the examiner concluded that it was less likely as not that medications the Veteran took for PTSD and atopic dermatitis, including Sertraline, Trazodone, and Triamcinolone cream) caused or aggravated his gout, as these medications were not believed to increase the incidence of gout. There is no other evidence of record suggesting that medications the Veteran has taken for his service-connected PTSD and atopic dermatitis caused or aggravated (permanently worsened) his gout or any other musculoskeletal disorder. The Veteran as a layperson does not have the medical training or expertise to render a competent opinion on this issue, as this is a determination that is too complex from a medical and scientific standpoint to be made based on lay observation alone. See Jandreau, 492 F. 3d at 1376-77; Barr, 21 Vet. App. at 309. Thus, his unsupported opinion is not competent and is outweighed by the VA examiner's conclusion that his gout was not related to the medications he has taken for his service-connected disorders. See King and Layno, both supra. Thus, the preponderance of the evidence weighs against a relationship, either by way of causation or aggravation, between medications the Veteran has taken for his service-connected PTSD and atopic dermatitis and his gout, arthritis, or another musculoskeletal disorder such as tendonitis of the shoulder. The Veteran has not argued, and there is no evidence otherwise showing that his PTSD itself has caused or aggravated his gout or arthritis. The Veteran did submit an article discussing the effects of stress on health, but the article does not suggest that PTSD or a psychiatric disorder can cause or aggravate gout or arthritis. Thus, this article is not relevant and does not support the Veteran's claim. Moreover, whether stress from PTSD caused or aggravated a musculoskeletal disorder is a determination that is too complex to be made based on lay observation alone. See Jandreau, 492 F. 3d at 1376-77; Barr, 21 Vet. App. at 309. Thus, the Veteran's lay testimony on this issue is not competent. See King, 700 F.3d at 1345; Layno, 6 Vet. App. at 469. Moreover, there is no indication in the record that his gout or arthritis may be related to stress. Accordingly, service connection for muscle and joint pain due to gout, arthritis, or tendonitis is not warranted on a secondary basis as being caused or aggravated by PTSD or by medications the Veteran has taken for PTSD and atopic dermatitis. See 38 C.F.R. §§ 3.102, 3.310. The Veteran also argues that his gout or arthritis was caused by chemical exposure during active service, including herbicide exposure and exposure to other chemicals or substances such as lead, depleted uranium, and the components in TNT. The preponderance of the evidence is against a finding of any relationship between the Veteran's musculoskeletal disorders, including gout and arthritis, and exposure to herbicides such as Agent Orange. Specifically, VA regulations provide that certain diseases associated with exposure to herbicide agents may be presumed to have been incurred in service even if there is no evidence of the disease in service, provided the requirements of 38 C.F.R. § 3.307(a)(6) are met. See 38 C.F.R. § 3.309(e). The term "herbicide agent" means a chemical in an herbicide, including Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam during the Vietnam era. 38 C.F.R. § 3.307(a)(6). A veteran who during active military, naval, or air service served in the Republic of Vietnam during the period beginning January 9, 1962 and ending on May 7, 1975 shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence establishing that the veteran was not exposed to any such agent. 38 U.S.C.A. § 1116(f); 38 C.F.R. § 3.307(a)(iii). The Veteran's service personnel records show that he served in Vietnam during the applicable time frame. Therefore, VA presumes that he was exposed to herbicides such as Agent Orange while on active duty. However, in order to benefit from the presumption of service connection for diseases associated with herbicide exposure, the Veteran must have one of the diseases enumerated in section 3.309(e). The diseases presumed to be caused by herbicide exposure are as follows: AL amyloidosis, chloracne or other acneform disease consistent with chloracne, Type 2 diabetes (also known as Type II diabetes mellitus or adult- onset diabetes), Hodgkin's disease, ischemic heart disease, all chronic B-cell leukemias (including, but not limited to, hairy-cell leukemia and chronic lymphocytic leukemia), multiple myeloma, non- Hodgkin's lymphoma, Parkinson's disease, acute and subacute peripheral neuropathy, porphyria cutanea tarda, prostate cancer, respiratory cancers (cancer of the lung, bronchus, larynx, or trachea), and soft-tissue sarcoma (other than osteosarcoma, chondrosarcoma, Kaposi's sarcoma, or mesothelioma). As the Veteran's gout, arthritis, and tendonitis are not among the diseases listed in 3.309(e), service connection on a presumptive basis for diseases associated with herbicide exposure is not warranted. See 38 C.F.R. § 3.307. Although service connection for the Veteran's musculoskeletal disorders may not be granted on a presumptive basis as related to herbicide exposure, he may still establish service connection with proof of actual direct causation. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); McCartt v. West, 12 Vet. App. 164, 167 (1999). There is no competent evidence of record suggesting that there is a relationship between gout, arthritis, tendonitis or similar musculoskeletal disorders and herbicide exposure. Specifically, under the authority granted by Congress in the Agent Orange Act of 1991 and the Veterans Education and Benefits Expansion Act of 2001, the Secretary of VA (Secretary) has determined that there is no positive association between exposure to herbicides and any other condition for which he has not specifically determined that a presumption of service connection is warranted. See Determinations Concerning Illnesses Discussed in National Academy of Sciences Report: Veterans and Agent Orange: Update 2010, 77 Fed. Reg. 47,924,47,925 (Aug. 10, 2012) (hereinafter "Update); see also Notice on Health Outcomes Not Associated With Exposure to Certain Herbicide Agents (hereinafter "Notice"), 75 Fed. Reg. 81332, 81333 (December 27, 2010); Notice, 72 Fed. Reg., 32395, 32407 (June 12, 2007). This determination is based on periodic reports of the National Academy of Sciences (NAS) based on a comprehensive review of scientific and medical literature on potential health effects of exposure to Agent Orange. See Update, 77 Fed. Reg. at 47,925; see also 72 Fed. Reg. at 32395-96, 32407. Congress has mandated that NAS determine, to the extent possible, whether there is a statistical association between "suspect diseases" and exposure to herbicide agents. Update, 77 Fed. Reg. at 47,925. The comprehensive review and evaluation of the available literature that NAS conducted in conjunction with its report has permitted VA to identify all conditions for which the current body of knowledge supports a finding of an association with herbicide exposure. Notice, 72 Fed. Reg. at 32407. In a September 2005 private treatment record, the Veteran's physician diagnosed arthritis and several other conditions, and stated that the Veteran was "experiencing [arthritis and the other conditions] in relationship to Agent Orange in Vietnam." This statement is accompanied by a question mark on the side, suggesting that the physician was not making an assertion or providing an opinion so much as indicating that this was the issue presented by the Veteran. The physician also noted in this record that the Veteran was trying to establish a service connection claim for this disorder, which suggests that the physician was not necessarily making an independent, objective medical assessment. Because the physician's statement is not supported by any explanation and cites to no medical or scientific data to support it, it carries no weight and thus does not support the Veteran's claim. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that the probative value of a medical opinion comes from its reasoning, and therefore is not entitled to any weight if it contains only data and conclusions). There is also no indication that this physician, although a medical doctor, has the appropriate scientific expertise to render a competent opinion on this issue in the first instance. In this regard, its complexity clearly requires scientific studies to determine whether there is a statistically significant relationship between herbicide exposure and the disease in question, as indicated by the Secretary's Notices on the health outcomes of herbicide exposure. Indeed, the omission of arthritis from the Secretary's Notices weighs against the physician's statement, as the omission indicates that arthritis is not even suspected as a possible health outcome of herbicide exposure based on current research. The Veteran also submitted articles on the health effects of dioxin, which is a chemical component of Agent Orange. However, these articles do not mention musculoskeletal disorders such as gout and arthritis. In a statement the Veteran submitted with the articles, he wrote that dioxin can cause "severe joint pain." This assertion appears to be in reference to the article "Health Effects of Dioxins," which states that chloracne is a skin disease associated with dioxins that is often accompanied by "severe joint pain," among other symptoms. While chloracne is recognized by VA under section 3.309(e) as being associated with herbicide exposure, the Veteran has not been diagnosed with chloracne. The article does not state that the "severe joint pain" is associated with gout or arthritis or even mention such disorders. Thus, the articles and treatises submitted by the Veteran do not support a relationship between herbicide exposure and his musculoskeletal disorders. As a layperson, the Veteran does not have the medical or scientific expertise to provide a competent opinion as to whether his musculoskeletal disorders were caused or aggravated by herbicide exposure, as this is a determination that is too complex, both from a medical and scientific standpoint, to be made based on lay observation alone. See Jandreau, 492 F. 3d at 1376-77; Barr, 21 Vet. App. at 309. Thus, the Veteran's unsupported statements do not support his claim and are outweighed by the fact that his musculoskeletal disorders are not even suspected of being associated with herbicide exposure, as shown in the Secretary's Update and Notices discussed above regarding the health outcomes of herbicide exposure. See King and Layno, both supra. Accordingly, the preponderance of the evidence is against a finding of a relationship between the Veteran's musculoskeletal disorders and herbicide exposure. With regard to other alleged chemical exposure, the Veteran argued at the December 2012 hearing, in his June 2007 notice of disagreement (NOD), and elsewhere that he was exposed to lead, the components of TNT, and depleted uranium during active service and that this exposure caused or aggravated his musculoskeletal disorders. He stated that he was exposed to these substances from being in proximity to exploding shells, from discharging firearms, and from sleeping in "contaminated soil." With regard to depleted uranium, the article submitted by the Veteran, "Depleted Uranium: A Review of its Properties, Potential Danger, and Recent Use in Yugoslavia" by Sonali Kolhatkar, states that the first military use of depleted uranium in weapons was in 1991 during the Gulf War, which weighs against a finding that it was used during the Veteran's service in Vietnam. There is no evidence that depleted uranium was used in Vietnam, and the Veteran has not provided any other support or explanation for this assertion. Thus, the preponderance of the evidence shows that the Veteran was not exposed to depleted uranium during active service. With regard to TNT, the Veteran submitted a public health assessment report from the Agency for Toxic Substances and Disease Registry (ATSDR) addressing pollutants generated from the TNT production process. The article does not state that explosions of shells that have TNT as a component cause meaningful exposure to the chemicals used in TNT production. There is no other evidence suggesting that being in proximity to exploding shells, mortars, or rockets or discharging firearms involves meaningful exposure to any chemicals or toxic substances associated with TNT. The Veteran himself, as a layperson, does not have the medical or scientific expertise to render a competent opinion in this regard, as this determination is too complex to be made based on lay observation alone. See Jandreau, 492 F. 3d at 1376-77; Barr, 21 Vet. App. at 309. Thus, his statement is not accorded any weight and does not support his claim in the absence of any medical or scientific evidence indicating that mere proximity to exploding shells or exploding TNT results in meaningful exposure to the chemicals used in its production. The speculative nature of this assertion also does not support his claim. See 38 C.F.R. § 3.102 (providing that in order for the benefit-of-the-doubt rule to apply, there must be some "positive" evidence supporting the claim such that the doubt is "within the range of probability as distinguished from pure speculation or remote possibility"). Finally, with regard to lead exposure, the Veteran submitted an article which states that adults can be exposed to lead from making bullets or shooting in indoor firing ranges, among other possible sources of exposure. However, while the Veteran was unquestionably exposed to armament during military service, determining his exposure, both indoors and outdoors, would be a matter of speculation. The Veteran's mere assertion that he was exposed to lead from firearms, exploding shells, and from sleeping in "contaminated soil" is not competent evidence as a lay person cannot observe whether there was lead in these sources or whether there was lead exposure in terms of its potential health effects. See Jandreau, 492 F. 3d at 1376-77; Barr, 21 Vet. App. at 309. Thus, this statement by itself has no weight and does not support his claim. See King, and Layno, both supra. Notably, although an article submitted by the Veteran suggests an association between gout and lead exposure, his treating physician at VA, who has both an MD and a Ph.D., stated in a July 2008 VA treatment record that it was "unlikely that [the Veteran's] gout is related [to lead exposure in service] since any lead exposure would certainly be relieved at this point." This opinion by a medical professional constitutes probative evidence against a relationship between the Veteran's alleged in-service lead exposure and gout. Accordingly, the preponderance of the evidence is against a finding of a relationship between the Veteran's musculoskeletal disorders, including gout and arthritis, and exposure to chemicals during active service, including lead, depleted uranium, and TNT. The evidence does not otherwise support a relationship between the Veteran's musculoskeletal disorders and service. His service treatment records do not reflect diagnoses of arthritis, gout, or other pathology of the bones, joints, or muscles. In November 1967, the Veteran did report a one-month history of an aching back. However, no disease or pathology was found. The service treatment records do not otherwise show complaints or treatment of joint or muscle pain. The March 1969 separation examination report shows that the Veteran's spine and upper and lower extremities were clinically evaluated as normal. In the accompanying report of medical history, he denied recurrent back pain, arthritis, swollen or painful joints, painful or "trick" shoulder or elbow, or "trick" or locked knee. The Veteran does not argue that he had ongoing back pain or other musculoskeletal pain during active service. Thus, the evidence does not show that a chronic disability manifested in service. There is no evidence after service of back pain until a July 2005 VA treatment record, in which the Veteran reported a two-week history of back pain without any precipitating cause. This long period of time of over thirty-five years between the Veteran's separation from service and the onset of back pain in July 2005, without evidence of ongoing or repeated back problems in the interim weighs against a relationship to service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (holding that a proper consideration for the trier of fact is the amount of time that has elapsed since military service, and that evidence of a prolonged period without medical complaint can be considered, along with other factors concerning the Veteran's health and medical treatment during and after military service, as evidence of whether a condition was incurred in service). Although the Veteran stated at the December 2012 hearing that his musculoskeletal pain had been present since the 1970's, and although he reported in a February 2006 VA treatment record that he was diagnosed with gout or arthritis in the 1980's, there is no evidence linking it to any disease, injury, or event in service, from which he separated in March 1969. See Shedden, 381 F.3d at 1166-67. In this regard, as already noted, his back pain had resolved well over a year prior to separation, he did not report any other musculoskeletal pain, and no pathology with regard to the back or the musculoskeletal system was diagnosed during that time. Moreover, with respect to gout and tendonitis, evidence of a continuity of symptomatology by itself is not sufficient to establish service connection, as these disorders are not listed as chronic disabilities in section 3.309(a). See Walker, supra. (holding that evidence of a continuity of symptomatology can only support service connection for those chronic disabilities recognized by VA in section 3.309(a); otherwise, a causal relationship must be shown between the current disability and the disease or injury incurred in or aggravated by service-the "medical nexus" element-to establish the claim). The Veteran has not stated and there is no evidence otherwise showing that he was diagnosed with arthritis within one year of discharge. Thus, service connection on a presumptive basis for a chronic disability under sections 3.307 and 3.309(a) of the regulations cannot be granted. Accordingly, the preponderance of the evidence is against the Veteran's claim. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for disorders of the muscles and joints, including gout and arthritis, must be denied. See 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. V. Withdrawal of Appeal The Veteran submitted a December 2012 written statement bearing his name and claim number in which he wrote that he was withdrawing his service connection claim for depression. He confirmed his wish to withdraw this appeal at the December 2012 Board hearing, which has been reduced to writing by virtue of the transcript. VA regulation provides for the withdrawal of an appeal to the Board by the submission of a written request to that effect at any time before the Board issues a final decision on the matter in question. See 38 C.F.R. § 20.204(b) (2012). After an appeal is transferred to the Board, an appeal withdrawal is effective the date it is received by the Board. 38 C.F.R. § 20.204(b). Appeal withdrawals must be in writing and must include the name of the Veteran, the applicable claim number, and a statement that the appeal is withdrawn. Id. As of February 2013, the date that the Board received the claims file, including the December 2012 letter, the Board had not yet issued a final decision on this case. The December 2012 statement and hearing transcript are in writing, include the Veteran's name and claim number, and clearly express his desire to withdraw the appeal of the denial of service connection for depression. Therefore, the Veteran's withdrawal of this appeal is valid. See id. When pending appeals are withdrawn, there is no longer an allegation of error of fact or law with respect to the determinations that had been previously appealed. Consequently, in such an instance, dismissal of the appeal of the denial of service connection for depression is appropriate. See 38 U.S.C.A. § 7105(d). Accordingly, further action by the Board on the claim at issue is not appropriate and the Veteran's appeal should be dismissed. Id. ORDER Entitlement to service connection for disorders of the muscles and joints, including gout and arthritis, is denied. Entitlement to service connection for depression, to include as secondary to PTSD, is dismissed. REMAND Hypertension A VA opinion is warranted on the issue of whether the Veteran's hypertension was caused or aggravated by PTSD. Although the July 2006 VA opinion addressed the issue of whether the Veteran's hypertension was related to medications he has taken for PTSD, an opinion was not provided on whether PTSD directly caused or aggravated the Veteran's hypertension. VA's National Center for PTSD has posted an article on its website entitled "PTSD and Physical Health" by Kay Jankowsi, Ph.D., that states that a number of studies have found an association between PTSD and poor cardiovascular health, including hypertension. See http://www.ptsd.va.gov/professional/pages/ptsd-physical-health.asp. The Court noted this article in an unpublished memorandum decision and remanded a service connection claim for a heart disorder, including hypertension, as secondary to PTSD so that the article could be taken into account by a VA examiner. See Jones v. Shinseki, No. 10-3915 (Vet. App. 2012). The Veteran also submitted a citation to an article on the website for the company Health Integrated which states that "several research studies reveal that there may be a significant link between hypertension and PTSD." See http://www.healthintegrated.com/industryinsight/?p=116#more-116. Accordingly, because there is some competent evidence suggesting that there may be a link between the Veteran's hypertension and his service-connected PTSD, a VA opinion addressing this issue should be provided in accordance with VA's duty to assist under the VCAA. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon , 20 Vet. App. at 83. Headache Disorder A VA opinion is warranted on the issue of whether the Veteran has a headache disorder caused or aggravated by his service-connected PTSD. A January 2002 VA treatment record reflects that the Veteran had tension headaches. VA treatment records dated in January 2005 and March 2005 reflect that the Veteran reported having headaches when he was at work or around people, but improved or resolved when he was at home. Because there is an indication that the Veteran's PTSD may cause or aggravate his tension headaches, a VA opinion should be provided as to whether he has a headache disorder caused or aggravated by PTSD, in accordance with the duty to assist. See 38 U.S.C.A. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon, 20 Vet. App. at 83. The Veteran's submission of a January 2002 VA treatment record mentioning his headache disorder indicates that there are earlier VA treatment records potentially relevant to this claim. Apart from this record, the claims file only contains VA treatment records dating from January 2004. The RO/AMC should obtain the Veteran's outstanding VA treatment records dating from January 2002, or earlier, to January 2004, as well as any outstanding VA treatment records dating from August 2012 forward. Accordingly, the case is REMANDED for the following actions: 1. Obtain the Veteran's outstanding VA treatment records dating from January 2002 to January 2004, as well as from August 2012 forward. If VA treatment records dating prior to January 2002 are identified, these should be obtained as well. If the RO/AMC is unable to obtain these records, then all efforts to obtain them must be documented and associated with the file, and the Veteran must be notified of this fact and provided an opportunity to submit them himself. 2. A VA opinion must be obtained as to whether the Veteran's PTSD caused or aggravated his hypertension. The following considerations will govern the opinion: a) The entire claims file and a copy of this REMAND must be made available to the medical professional rendering an opinion on this claim. The opining medical professional must note in the opinion that the evidence in the claims file has been reviewed. b) The medical professional should also review the following articles, if they are still available, addressing a possible relationship between PTSD and cardiovascular disorders: i. The article "PTSD and Physical Health," by Kay Jankowsi, posted on VA's National Center for PTSD website at http://www.ptsd.va.gov/professional/pages/ptsd-physical-health.asp. ii. The article on PTSD and hypertension referenced by the Veteran, which can be found at http://www.healthintegrated.com/industryinsight/?p=116#more-116. c) Then, after reviewing any other pertinent articles or studies, an opinion must be provided as to whether the Veteran's hypertension was caused or aggravated (permanently worsened) by his service-connected PTSD. THE EXAMINER MUST SPECIFICALLY CONSIDER AND REPORT AS TO BOTH THE QUESTION OF CAUSE AND THE QUESTION OF PERMANENT WORSENONG ("AGGRAVATION"). d) The VA medical professional must provide a complete explanation for his or her opinion(s), based on his or her clinical experience, medical expertise, and established medical principles. 3. A VA medical opinion should also be obtained as to whether the Veteran has a headache disorder caused or aggravated by his service-connected PTSD. The following considerations will govern the opinion: a) The entire claims file and a copy of this REMAND must be made available to the medical professional rendering an opinion on this claim. The opining medical professional must note in the opinion that the evidence in the claims file has been reviewed. b) An opinion should be provided as to whether the Veteran has a headache disorder which was caused or aggravated (permanently worsened) by his service-connected PTSD. THE EXAMINER MUST SPECIFICALLY CONSIDER AND REPORT AS TO BOTH THE QUESTION OF CAUSE AND THE QUESTION OF PERMANENT WORSENONG ("AGGRAVATION"). c) The VA medical professional must provide a complete explanation for his or her opinion(s), based on his or her clinical experience, medical expertise, and established medical principles. 4. After the above development is completed, and any other development that may be warranted based on any additional information or evidence received, the RO/AOJ should readjudicate the claims on the merits. If the benefits sought are not granted, the Veteran and his representative should be furnished a supplemental statement of the case (SSOC) and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655 (2012). 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). ______________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs