Citation Nr: 1311952 Decision Date: 04/10/13 Archive Date: 04/19/13 DOCKET NO. 09-07 608 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUES 1. Entitlement to service connection for hypertension, including as due to exposure to herbicides and as secondary to service-connected diabetes mellitus and PTSD. 2. Entitlement to service connection for arthritis, including as due to exposure to herbicides and as secondary to service-connected diabetes mellitus and PTSD. 3. Entitlement to service connection for a prostate condition, including as due to exposure to herbicides and as secondary to service-connected diabetes mellitus and posttraumatic stress disorder (PTSD). 4. Entitlement to service connection for prostate stones, including as due to exposure to herbicides and as secondary to service-connected diabetes mellitus and PTSD. REPRESENTATION Appellant represented by: Missouri Veterans Commission WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Erdheim, Counsel INTRODUCTION The Veteran served on active duty from July 1966 to June 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, that denied the above claims. In August 2009, the Veteran was afforded a personal hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In November 2009, March 2011, and August 2012, the Board remanded the issues for additional development. FINDINGS OF FACT 1. Hypertension is not shown to be causally or etiologically related to any disease, injury, or incident in service, did not manifest within one year of the Veteran's discharge from service, is not due to herbicide exposure in service, and is not etiologically related to or aggravated by the service-connected diabetes mellitus or PTSD. 2. Rheumatoid arthritis and osteoarthritis of the joints is not shown to be causally or etiologically related to any disease, injury, or incident in service, did not manifest within one year of the Veteran's discharge from service, is not due to herbicide exposure in service, and is not etiologically related to or aggravated by the service-connected diabetes mellitus or PTSD. 3. A prostate condition is not shown to be causally or etiologically related to any disease, injury, or incident in service, is not due to herbicide exposure in service, and is not etiologically related to or aggravated by the service-connected diabetes mellitus or PTSD. 4. Prostate stones are not shown to be causally or etiologically related to any disease, injury, or incident in service, is not due to herbicide exposure in service, and is not etiologically related to or aggravated by the service-connected diabetes mellitus or PTSD. CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated by the Veteran's active duty military service, nor may it be presumed to have been incurred in or aggravated by service, nor is it caused or aggravated by any service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 2. Rheumatoid arthritis and osteoarthritis of the joints were not incurred in or aggravated by the Veteran's active duty military service, nor may they be presumed to have been incurred in or aggravated by service, nor are they caused or aggravated by any service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309, 3.310 (2012). 3. A prostate condition was not incurred in or aggravated by the Veteran's active duty military service, nor may it be presumed to have been incurred in or aggravated by service, nor is it caused or aggravated by any service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2012). 4. Prostate stones were not incurred in or aggravated by the Veteran's active duty military service, nor may it be presumed to have been incurred in or aggravated by service, nor are they caused or aggravated by any service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1116, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist 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). In this case, the Board finds that VA has satisfied its duty to notify in letters to Veteran in July 2007, August 2007 and January 2008. The claims were subsequently readjudicated in a January 2009 statement of the case. Mayfield, 444 F.3d at 1333. Relevant to the duty to assist, the Veteran's service treatment and personnel records as well as post-service VA treatment records have been obtained and considered. The Veteran has not properly identified any additional, outstanding records that have not been requested or obtained. The Board has also reviewed the Veteran's Virtual VA claims file. The duty to assist also provides that VA will afford a claimant a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim. 38 C.F.R. § 3.159(c)(4). In this case, the Veteran was afforded multiple VA examinations and multiple VA opinions have been obtained. The Board finds that the examination reports, as a whole, are adequate as the examiners had knowledge of the relevant facts in regards to the Veteran's military and post-service medical history, and the medical conclusions are supported with data and a rationale. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Court held in Bryant v. Shinseki, 23 Vet. App. 488, 493-94 (2010) that there are two duties imposed by 38 C.F.R. 3.103(c)(2), (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked, which are not impacted by the Veteran's receipt of a compliant notice letter. At the August 2009 hearing, the Veterans Law Judge explained the law regarding herbicide presumptions and secondary service connection in relation to the Veteran's claims. The evidence elicited demonstrated knowledge of the elements of direct service connection. All pertinent records were identified. The claims were remanded in November 2009, March 2011, and August 2012 in order to obtain VA opinions and associate records with the file so that the RO could review the evidence, to include a June 2011 VA examination, in the context of the claims at hand. Those directives have been accomplished. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis 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). Under 38 C.F.R. § 3.303(b), for those conditions considered to be chronic according to 38 C.F.R. § 3.309(a), a claimant may establish the second and third elements by demonstrating continuity of symptomatology. See Barr v. Nicholson, 21 Vet.App. 303 (2007); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including cardio-vascular renal disease and arthritis, to a degree of 10 percent within one year from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. For injuries alleged to have been incurred in combat, 38 U.S.C.A. § 1154(b) (West 2002) provides a relaxed evidentiary standard of proof to determine service connection. Collette v. Brown, 82 F.3d 389 (Fed. Cir. 1996). When an injury or disease is alleged to have been incurred or aggravated in combat, such incurrence or aggravation may be shown by satisfactory lay evidence, consistent with the circumstances, conditions, or hardships of combat, even if there is no official record of the incident. 38 U.S.C.A. § 1154(b)(West 2002); 38 C.F.R. § 3.304(d) (2012). However, although the Veteran did take part in combat while in service, he does not allege that the claims on appeal were incurred in combat. Rather, the disabilities on appeal are argued to stem from herbicide exposure or service-connected disabilities. VA regulations provide that a Veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period from January 9, 1962, to May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service. 38 U.S.C.A. § 1116; 38 C.F.R. § 3.307(a)(6)(iii). For purposes of applying the presumption of exposure to herbicides under 38 C.F.R. § 3.307(a)(6)(iii), the serviceman must have actually been present on the landmass or the inland waters of Vietnam during the Vietnam era. See Haas v. Peake, 525 F.3d 1168 (Fed. Cir. 2008). Certain diseases shall be service-connected if the Veteran was exposed to an herbicide agent during active service even though there is no record of such disease during service, provided that the requirements of 38 C.F.R. § 3.307(d) are satisfied. 38 C.F.R. § 3.309(e). The Veteran's DD-214 form reflects that he served in Vietnam during the Vietnam War. The Veteran was present on the landmass or the inland waters of Vietnam during service. Thus, the Veteran will be afforded the herbicide presumption. However, only those diseases associated with exposure to certain herbicide agents, listed in 38 C.F.R. § 3.309(e) (2012) will be considered to have been incurred in service under the circumstances outlined in that section even though there is no evidence of such disease during the period of service. Hypertension, rheumatoid arthritis, benign prostate hypertrophy, and prostate stones are not diseases that have been associated with exposure to herbicide agents. 38 C.F.R. §§ 3.307(a)(6)(iii); 3.307(d), 3.309(e) (2012). Accordingly, because the Veteran cannot prevail on the theory of herbicide presumption, the Board will instead adjudicate the claims on a direct basis. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Hypertension In statements of record and at his hearing before the Board, the Veteran contends that his hypertension was caused or aggravated by his service, or was due to exposure to herbicides in service. He also contends that his hypertension was caused or aggravated by his diabetes mellitus. He alternatively contends that his hypertension was caused or aggravated by his PTSD, in that medication that he took for PTSD-related nightmares would interfere with his blood pressure by lowering it. Service treatment records are negative for any indication of hypertension or elevated blood pressure. VA treatment records reflect that in July 2007, the Veteran had elevated blood pressure readings but no diagnosis of hypertension. In August 2007, the Veteran had a history of elevated blood pressure readings that were normal on examination. In November 2007, the Veteran was diagnosed with hypertension and he was to start Lisinopril. In February 2009, the Veteran's psychiatrist noted that the Veteran was taken off of Prazosin which was not helping his sleep or nightmares and was lowering his blood pressure too much. He was to be evaluated for his blood pressure as he was unable to tolerate Lisinopril in the past. In March 2009, the Veteran's VA psychiatrist wrote a note concerning the possible effects of the Veteran's PTSD on his hypertension. She explained that the literature did support that the presence of a mental illness such as PTSD could contribute to the symptoms of hypertension and heart disease. Since they had been having some difficulty getting his symptoms under control, there was a real possibility that the Veteran's medical illnesses could be influenced by his mental status. She stated that if you look at the literature there were not only effects on serotonin but also on norepinephrine in PTSD which could cause autonomic arousal and sympathetic activation, which increased blood pressure and pulse rate. Blood sugars were also known to rise in flight or fight responses. There were articles to support increased rates of a wide range of medical disorders in trauma survivors, including hypertension and musculoskeletal disorders. In March 2009, the Veteran submitted an article which linked soldiers who had experienced trauma in battle with the development of later chronic medical disabilities, such as heart trouble and arthritis. The stress began as a psychological phenomenon and then eventually affected the body systems by causing the endocrine system to produce a steady stream of hormones and other chemicals that attacked the body of many years, wearing it down. Combat veterans were also shown to have abnormally high white blood cell counts due to the effects of mental illness on their bodies. VA treatment records reflect that in July 2009, the Veteran's hypertension was not well controlled. However, his diabetes mellitus was resolved, controlled with diet. On December 2009 VA examination, it was noted that the Veteran had presented to the VA in 2007 after a seven year lapse with a history of a progressive increase in muscle and joint pain which had begun about six months previously. He had elevated blood pressure on his first presentation and was first placed on blood pressure medication in June 2007. His blood pressure varied somewhat with steroid treatment for his rheumatoid arthritis and his pain, and he developed an allergy to his blood pressure medication which was discontinued. He was placed on a new medication in August 2008. The examiner stated that although the Veteran did see a great deal of combat during his three years in Vietnam, for which he was awarded a Bronze Star, his PTSD had appeared stable and did not require treatment until 2007, which correlated with his progressive increase in muscular and joint pain. In October 2009, the Veteran was noted to have disturbing dreams, which had been stable for 40 years, and recently had changed to include other hand-to-hand fighting, and that the intensity had increased to several times per week from three to four times per month. He had worked full-time as a pastor for 37 years. Although it was unknown when he developed diabetes and hypertension, he did not suffer from those disabilities in 2000. Renal functions were normal. After conducting physical examination, the examiner concluded that the Veteran's hypertension was not related to his service, and was not caused or aggravated by his PTSD. He did not develop hypertension until at least 2000, more than 30 years following separation from service. He developed hypertension in connection with other illnesses, such as his rheumatoid arthritis, which required medication that was known to raise blood pressure. His PTSD had been stable for decades and required no treatment until the development of rheumatoid arthritis. Thus, the rheumatoid arthritis and hypertension appeared to have triggered the flare-up of PTSD in the Veteran. In December 2009, in an addendum to the VA examination, a VA examiner reviewed the article relating PTSD with the development of physical disabilities and the March 2009 VA opinion linking PTSD with the development of medical disorders. The examiner opined that although the Veteran had PTSD upon returning home from Vietnam, he did not require treatment for PTSD until his health deteriorated in 2007. His hypertension was not diagnosed until he had diabetes, prostatic hypertrophy, and rheumatoid arthritis. Those conditions would be far more likely to provoke stress-induced hypertension than his longstanding PTSD. Therefore it was less likely than not that his hypertension was the result of his PTSD. In April 2011, a VA examiner concluded that the Veteran's hypertension was less likely than not related to service, including herbicide exposure, and was not caused or aggravated by his PTSD. The examiner explained that the Veteran was first noted to have elevated blood pressure in June 2007, and was not diagnosed with hypertension until November 2007. Rheumatoid arthritis was painful and that would raise blood pressure, as well as the medications used to treat rheumatoid arthritis. The fact that the Veteran's hypertension occurred late in life and in association with rheumatoid arthritis linked it to rheumatoid arthritis, not to PTSD. It was far more likely that his PTSD had been exacerbated by his pain and hypertension than that either disability was caused by his PTSD. On June 2011 VA examination, the Veteran's essential hypertension was found to not be related to or aggravated by his diabetes as his renal function had been normal. In August 2012, a VA examiner opined that the Veteran's hypertension was not caused or aggravated by herbicide exposure or his diabetes or PTSD. The examiner explained that the Veteran had essential hypertension and was being treated with appropriate medications. Age, body habitus, and physical deoconditioning and genetics were primary influences on essential hypertension. His diabetes mellitus had been well-controlled. For his diabetes to have influenced his hypertension, it would have to be so poorly controlled to the point that renal damage had occurred. There was no indication of renal damage. Anxiety and hypervigilent conditions secondary to PTSD could cause brief spikes in blood pressure, but as the patient calmed emotionally, the blood pressure would return to baseline for a patient being treated with essential hypertension. Chronic elevation of hypertension was due to control of essential hypertension with medication and prescribed practice, as well as the patient's compliance with those variables. An evaluation of the probative value of medical evidence is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467 (1993). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). In this case, the Board finds that the preponderance of the evidence is against the claim for service connection for hypertension, on either a direct or secondary basis. First, as pointed out by the December 2009, April 2011, and August 2012 VA examiners, there is no indication of hypertension while in service or for more than 30 years following separation from service. There is no medical link between the current hypertension, diagnosed as essential hypertension, and service. Therefore, service connection on a direct basis is not warranted. Nor is service connection warranted for hypertension on a presumptive basis, as there was no indication of a diagnosis of hypertension in the one year following service. Rather, hypertension was first diagnosed in 2007. And, as explained above, because hypertension is not considered to be a presumptive disease associated with exposure to herbicides, service connection is not warranted on that basis either. In that regard, as was pointed out by multiple VA examiners, the Veteran's essential hypertension began later in life and was due to such factors as the onset of his rheumatoid arthritis, as well as such factors as age, body habitus, physical deconditioning, and genetics. Thus, the VA examiners found no correlation between the development of hypertension and the Veteran's service, including his exposure to herbicides in service on a direct basis. With regard to service connection for hypertension on a secondary basis, the Board finds that the preponderance of the evidence is against a finding that it was caused or aggravated by the Veteran's PTSD or diabetes. With regard to his PTSD, the Board has considered the March 2009 statement by the Veteran's psychiatrist and the articles submitted by the Veteran, however, the Board finds that the December 2009, April 2011, and August 2012 VA opinions are more probative and thus outweigh that evidence. Specifically, the March 2009 statement is general in nature in that it summarizes articles showing a correlation between long term PTSD symptoms and hypertension. While the psychiatrist did relate those findings to the Veteran in stating that he was having difficulty getting his PTSD symptoms under control, there is no indication that the psychiatrist reviewed the Veteran's medical records when making tying the Veteran to the research. In so doing, the VA psychiatrist did not account for the late onset of hypertension that had been medically linked with the onset of rheumatoid arthritis and associated medication and increased pain. On the other hand, the VA examiners in this case were in agreement that the Veteran's development of hypertension closely correlated with the onset and treatment of rheumatoid arthritis. The Veteran was in fact diagnosed with hypertension shortly after beginning the use of steroids, which was determined to be a common outcome. The VA examiners concluded that the development of diabetes, prostatic hypertrophy, and rheumatoid arthritis which immediately predated the onset of hypertension were much more likely the cause of his hypertension, rather than his PTSD which had been stable for many years. Moreover, the March 2009 statement did not specifically address essential hypertension. As the August 2012 examiner pointed out, when it came to essential hypertension, anxiety and hypervigilence would cause momentary spikes in blood pressure but would not cause a permanent aggravation of the condition. In that regard, with regard to aggravation, the Board finds that the evidence does not support a finding that the Veteran's PTSD has aggravated his hypertension. The Veteran contends that his longstanding nightmares related to his PTSD caused a slow progression of heart disease as his body broke down, in accordance with the article that he submitted. The March 2009 psychiatrist also stated that his difficulty getting his symptoms under control could impact his health. However, those theories have been addressed by multiple VA examiners who were all in agreement that the Veteran's medical history instead demonstrated a flare-up of PTSD due to medical conditions, but not the other way around. The December 2009 VA examiner explained that although the Veteran suffered from PTSD upon returning from service, and thus suffered those symptoms for many years, treatment was not required until 2007. The Veteran himself reported to his psychiatrist that his nightmares had become worse and more frequent in 2007. On the other hand, his hypertension had its onset in correlation with the onset of other painful medical conditions. Thus, it was more likely, as the April 2011 VA examiner also concurred, that his PTSD was exacerbated by his newly diagnosed medical conditions, rather than the other way around. Accordingly, the Board finds that the competent and probative medical evidence demonstrates that, in this particular case, the Veteran's PTSD has not permanently aggravated his essential hypertension. It has been concluded that momentary spikes in blood pressure due to PTSD symptoms would not cause permanent aggravation of essential hypertension. Lastly, the Veteran contends that medication taken for his PTSD symptoms affected his blood pressure. However, a review of the record shows that the medication lowered his blood pressure but did not elevate it. Thus, there is no evidence to support a finding that his PTSD medication aggravated his hypertension by increasing blood pressure. With regard to his service-connected diabetes, the Board also find that the evidence is against the theory of aggravation. Both the June 2011 and August 2012 VA examiners' determined that the Veteran's hypertension was not caused or aggravated by his diabetes mellitus. In so finding, they explained that there was no indication of renal dysfunction. Rather, his hypertension was related to the onset of his rheumatoid arthritis, or to other factors, such as being overweight or as due to age. Accordingly, the claim for service connection for hypertension on a direct, presumptive, or secondary basis must be denied. Arthritis In statements of record and at his hearing before the Board, the Veteran contends that his current arthritis, rheumatoid arthritis and osteoarthritis of the joints, was caused or aggravated by his service, to include herbicide exposure in service that elevated his white blood cell count and caused break down of his body. That break down caused pain and arthritis in many of his joints, including his shoulders, hands, ankles, and feet. He alternatively contends that his arthritis was caused or aggravated by his longstanding PTSD or his diabetes. Service treatment records are negative for any indication of arthritis or painful joints. VA treatment records reflect that in June 2007, x-ray showed osteoarthritis of the hands. The Veteran had had stiffness in the hands for six months. In June 2007, he presented with aching muscles in his legs and thighs that went up his back. He also had muscle pain in the arms. He had increasing weakness, loss of muscle tone, and range of motion. Testing resulted in a diagnosis of rheumatoid arthritis. In August 2007, the Veteran's rheumatoid arthritis was improved on medication. A March 2008 VA psychiatric examination revealed that the Veteran's PTSD symptoms appeared to have increased within the past year as the Veteran experienced the onset of rheumatoid arthritis. The steroid treatment for his rheumatoid arthritis had led to an increase in his chronic tinnitus. The ringing in the ears had aroused painful memories of his Vietnam experience that were now overwhelming. He had previously tried to push away his Vietnam memories by throwing himself into his work as a minister. On December 2009 VA examination, it was noted that the Veteran had had severe myalgias in 2006 and 2007 until his white blood cell count was brought under control. He was doing better now and was able to unbutton his shirt. He was able to tend to activities of daily living as long as his white blood cell count was kept controlled. X-rays of the cervical spine had shown osteoarthritis. After physically examining the Veteran, the examiner stated that rheumatoid arthritis was not one of the conditions considered casually linked to Agent Orange exposure. The cause of rheumatoid arthritis was unknown, although infectious agents and genetic links were suspected. Review of the Veteran's timeline of onset made it seem far more likely that his PTSD was aggravated by his rheumatoid arthritis, rather than the other way around. Therefore, it was less likely than not that the Veteran's rheumatoid arthritis was related to his service, or that it was caused or aggravated by his PTSD. In December 2009, in an addendum to the VA examination, a VA examiner reviewed the article relating PTSD with the development of physical disabilities and the March 2009 VA opinion linking PTSD with the development of medical disorders. The examiner opined that the major risk factors for rheumatoid arthritis were female gender, older age, family history, white/American Indian ethnic background, obesity, and cigarette smoking. The Veteran had two of those risk factors. Therefore, it was less likely than not that his rheumatoid arthritis was due to his service-connected PTSD or diabetes. In April 2011, a VA examination determined that it was less likely than not that the Veteran's rheumatoid arthritis was related to service, to include herbicide exposure, or that it was caused or aggravated by his service-connected PTSD. The examiner explained that the first note of general joint and muscle pain was not until 2006, and he was diagnosed as seropositive in 2007. Rheumatoid arthritis was not considered to be linked to Agent Orange or PTSD. In August 2012, a VA examiner opined that the Veteran's osteoarthritis and/or rheumatoid arthritis were not caused by herbicide exposure, and was not aggravated by PTSD or diabetes. The examiner explained that herbicide exposure was not associated with or found to be causative of rheumatoid arthritis. The rheumatoid arthritis pre-dated the onset of diabetes. Finally, osteoarthritis was due to the natural progression of age, particularly with the history of being overweight. In this case, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for rheumatoid arthritis or osteoarthritis on a direct or secondary basis. On a direct basis, there is no indication of a diagnosis of arthritis in service. Rather, the first indication of arthritis was not until 2006, many years following service. Thus, there is no medical evidence to relate the arthritic conditions directly to service. Moreover, there is no indication of an arthritic condition developing within one year following separation from service, thus presumptive service connection is not warranted. On that note, because neither arthritic condition is considered to be a presumptive herbicide disability, service connection on that theory is also not warranted. Furthermore, despite the Veteran's contention that herbicide exposure led to an increase in white blood cell count that led to his rheumatoid arthritis, as noted by the December 2009 VA examiner, rheumatoid arthritis was not a condition that correlated with exposure to Agent Orange. Rather, the Veteran had two of the risk factors associated with the onset of rheumatoid arthritis, obesity and older age, and those factors were not related to service or herbicide exposure. Finally, as stated by the August 2012 VA examiner, the Veteran's osteoarthritis was due to the natural progression of age, only, in the Veteran's instance. With regard to service connection on a secondary basis, the Board finds that the evidence weighs against a finding that his PTSD or diabetes caused or aggravated his arthritic conditions. With regard to his PTSD, as explained above, the Board and the VA examiners have taken into account the March 2009 statement and the article submitted by the Veteran that longstanding PTSD in trauma victims could cause later musculoskeletal disabilities. However, as also explained above, those statements are general in nature and do not specifically encompass rheumatoid arthritis or osteoarthritis, and also do not provide insight as to the timeline of onset in the Veteran's particular case. Thus, they are assigned lower probative value when taking into account the VA opinions that do take into account the Veteran's personal medical history. To that extent, the December 2009 VA examiner found it to be far more likely that the Veteran's rheumatoid arthritis aggravated his PTSD because he first sought treatment for muscle and joint pains and such then began to exacerbate his tinnitus, reminding him of his war experiences and triggering a worsening of his PTSD. The April 2011 VA examiner stated that PTSD and rheumatoid arthritis were not considered to be linked, based upon medical knowledge. Accordingly, the competent and probative evidence demonstrates no medical link showing that his PTSD caused or aggravated his arthritic conditions. With regard to his diabetes, the December 2009 and August 2012 VA examiners both stated that there was no relationship between the Veteran's arthritic conditions and his diabetes. For one, his rheumatoid arthritis pre-dated the onset of diabetes. Moreover, diabetes was not considered to be related to either rheumatoid arthritis or osteoarthritis. Such opinions comport with the record, as there is no medical link in the treatment records to suggest that the Veteran's diabetes caused or aggravated his rheumatoid arthritis or osteoarthritis. Accordingly, there is an absence of evidence to link the Veteran's diabetes with his arthritic conditions, either caused or aggravated by such. Accordingly, the claim for service connection for rheumatoid arthritis or osteoarthritis of multiple joints on a direct, presumptive, or secondary basis must be denied. Prostate Condition and Prostate Stones In statements of record and at his hearing before the Board, the Veteran contends that his current prostate condition, benign prostate hypertrophy, and his prostate stones were caused or aggravated by his diabetes, as he was told by his physician. He also contends that those conditions were caused by exposure to herbicide agents, or to his longstanding PTSD related to combat experiences. Service treatment records are negative for any indication of a prostate condition. VA treatment records beginning in October 1999 reflect the Veteran's report of having had three urinary tract infections in the previous three years. He had hematuria. Following antibiotics, he was doing better. In August 2007, the Veteran was diagnosed with benign hypertrophy of the prostate that was stable as shown on biopsy. The biopsy had shown firmness of the right superior medial lobe. In November 2007, the Veteran was diagnosed with prostate stones. His physician stated that it was most likely that his prostate stones were caused from repeated infections mostly due to his diabetes. On November 2008 VA examination, it was noted that the Veteran was seen in 1999 and 2000 for urinary tract infections. At the time, he was thought to possibly have prostatitis and was treated with a longer course of antibiotics and had little problem since then. He was diagnosed with diabetes in 2007. He was not taking any medication for his diabetes and his blood sugars had oftentimes been in the normal range. In June 2007, it was found that he had diffuse calcifications involving the prostate. More recent urinalysis was normal. Physical examination showed a moderately enlarged prostate that was smooth with a slightly firm consistency. The November 2007 note relating the Veteran's prostate stones to his diabetes was reviewed. The VA examiner stated that he was unaware of an association between diabetes and prostate stones. The examiner explained that prostate stones were very common in most and were most often asymptomatic. There were found in association with urinary tract infections. It was also important to note that the Veteran had only recently been diagnosed with diabetes. With the number of stones that had been present for many years, it was not likely that there was a correlation between his diabetes and his prostate stones. On December 2009 VA examination, the examiner reviewed the Veteran's record and stated that there was no convincing research linking prostate stones and PTSD or Agent Orange exposure. The examiner reviewed the Veteran's record, including his history of urinary tract infections that resolved, and found it to be significant that his diabetes was diagnosed in 2007 which was after his only documented urinary tract infection. Thus, his prostate stones were not caused by, the result of, or aggravated by his service, PTSD, or diabetes. In December 2009, in an addendum to the VA examination, a VA examiner reviewed the article relating PTSD with the development of physical disabilities and the March 2009 VA opinion linking PTSD with the development of medical disorders. The examiner opined that with respect to the Veteran's prostate stones, there was no indication of frequent prostatitis. Prostate stones were very common in men over 50 and many elderly men evaluated for benign prostate hypertrophy had prostatic calculi. There were no serious studies linking diabetes or PTSD to prostate stones. Therefore, it was less likely than not that his prostate stones were causally related to his diabetes. On June 2011 VA examination, the Veteran reported that he used to have urinary tract infections more frequently, but in the past twelve months he had had one that he had treated with SULFA drugs. In May 2012, a VA examiner explained that the Veteran also suffered from benign prostate hypertrophy, a condition that universally affected all men as part of the normal aging process. That condition was not linked to PTSD, diabetes, or Agent Orange exposure. On August 2012 VA examination, a VA examiner opined that it was less likely than not that the Veteran's prostate stones or benign prostate hypertrophy were caused or aggravated by Agent Orange exposure, diabetes, or PTSD. They were also not aggravated by diabetes or PTSD. The examiner explained that PTSD had no physiological basis to cause benign prostate hypertrophy. That condition was not recognized to be related to herbicide exposure. The Veteran had had a single documented event of a urinary tract infection and that was acute, the etiology was unknown. There was no history of a chronic urinary tract infections. In this case, the Board finds that the preponderance of the evidence is against the Veteran's claims for service connection for a prostate condition or for prostate stones. On a direct basis, there is no indication of a diagnosis of a prostate condition or urinary tract infection in service. Rather, the first indication of prostate stones or benign prostate hypertrophy was not until 2007, many years following service. Thus, there is no medical evidence to relate the prostate conditions directly to service. Finally, because neither prostate condition is considered to be a presumptive herbicide disability, service connection on that theory is also not warranted. The VA examiners also found against the theory that his prostate conditions were directly related to herbicide exposure. The examiners explained that there was no known relationship between herbicide exposure and either prostate condition. There was nothing in the Veteran's presentation to suggest that his prostate conditions were related to his service, to include herbicide exposure. With regard to the theory of aggravation, specifically as due to his service-connected diabetes, the Board has taken into account the November 2007 physician statement that the Veteran's prostate stones were most likely due to repeated infections due to his diabetes. However, the Board finds that the competent VA medical opinions outweigh that statement. Significantly, as the VA examiners point out, particularly in December 2009, the Veteran had only recently been diagnosed with diabetes, yet the stones had been present for many years. Moreover, the VA examiner found no medical support to link diabetes and the development of prostate stones. As the May 2012 and August 2012 VA examiners also agreed, prostate stones were common in men over 50. Benign prostate hypertrophy, too, was a condition that universally affected men as part of the normal aging process. None of the four VA examiners who reviewed the record found any causal relationship between the Veteran's diabetes and his prostate stones or benign prostate hypertrophy. That four VA examiners reviewed the file, and all four provided detailed rationale as to why his prostate conditions were unrelated to his diabetes, namely because the two were not linked and the diabetes which was well-controlled had its onset in 2007. Therefore was no indication of a causal relationship or suggestion of aggravation. Thus, the Board finds that the lone November 2007 opinion is outweighed. Significantly, the November 2007 notation provides no rationale, including how his newly diagnosed diabetes had caused repeat infections. With regard to PTSD, the Board also finds that the evidence weighs against that claim. Notably, the VA examiners agreed that there was no relationship between PTSD symptoms and the development of prostate stones or benign prostate hypertrophy. There is no medical opinion or evidence of record to contradict those opinions. As explained above, the Veteran's prostate conditions were very common and were thus most likely due to the aging process. Therefore, it cannot be concluded that the prostate conditions were caused or aggravated by his PTSD. Accordingly, the claim for service connection for prostate stones or for benign prostate hypertrophy on a direct, presumptive, or secondary basis must be denied. III. Conclusion To the extent that the Veteran has submitted an article demonstrating the link between combat trauma and the development of heart and musculoskeletal disabilities, the Court has held that, generally, an attempt to establish a medical nexus between service and a disease or injury solely by generic information in a medical journal or treatise "is too general and inclusive." Sacks v. West, 11 Vet. App. 314, 317 (1998) (a medical article that contained a generic statement regarding a possible link between a service-incurred mouth blister and a present pemphigus vulgaris condition did not satisfy the nexus element). That article has been reviewed as to each element of the Veteran's claims for service connection by VA physicians, however, the VA physicians have found the article to be unpersuasive in the Veteran's case and with respect to the specific disabilities on appeal. As such, the article is afforded little probative value. The Veteran has contended on his own behalf that his prostate conditions, hypertension, and arthritic conditions, are related to his military service or to his service-connected disabilities. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), the specific issue in this case falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." Because, while the Veteran is competent to describe his joint pain, headaches related to hypertension, and perhaps some prostate symptoms such as difficulty urinating, the Board accords his statements regarding the etiology of such disorders less probative value as he is not competent to opine on such complex medical questions. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). Moreover, the Veteran has only offered conclusory statements regarding the relationship between his military service and service-connected PTSD and diabetes and his prostate conditions, hypertension, and arthritic conditions. By contrast, the multiple VA examiners took into consideration all the relevant facts in providing their opinions, as described in detail above. Therefore, based on the competent and probative evidence of record, the Board finds that service connection is not warranted for the Veteran's rheumatoid arthritis, osteoarthritis, prostate stones, benign prostate hypertrophy, or hypertension, as none of these conditions have been shown to have been causally or etiologically related to any disease, injury, or incident of service, or presumptively related to service, or to have been caused or aggravated by the service-connected PTSD or diabetes. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for prostate stones is denied. Service connection for a prostate condition is denied. Service connection for hypertension is denied. Service connection for arthritis is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs