Citation Nr: 1311968 Decision Date: 04/10/13 Archive Date: 04/19/13 DOCKET NO. 10-18 497 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES 1. Entitlement to service connection for neuroma of the right foot, to include as secondary to a service-connected disability. 2. Entitlement to service connection for neuroma of the left foot, to include as secondary to a service-connected disability. ATTORNEY FOR THE BOARD T. Y. Hawkins, Counsel INTRODUCTION The Veteran served on active duty from January 1971 to January 1975. These matters come to the Board of Veterans' Appeals ("Board") on appeal from a July 2009 rating decision issued by the Department of Veterans Affairs ("VA") Regional Office ("RO") in Muskogee, Oklahoma, which reopened and denied the Veteran's claim. The Board has previously considered this claim. In December 2012, the Board determined that new and material evidence had been received sufficient to reopen the previously denied claim. Thereafter, the Board remanded the claim for additional evidentiary development, specifically, to attempt to obtain updated VA treatment records and afford the Veteran a new VA examination. The requested development having taken place, the claim has now been returned to the Board for further appellate proceedings. FINDINGS OF FACT 1. The most probative evidence of record demonstrates that the Veteran's neuroma of the right foot was not present in service, is not the result of any incident of service, and is not otherwise shown to be causally-related to a service-connected disability. 2. The most probative evidence of record demonstrates that the Veteran's neuroma of the left foot was not present in service, is not the result of any incident of service, and is not otherwise shown to be causally-related to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for neuroma of the right foot, to include as secondary to a service-connected disability, are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310(a) (2012). 2. The criteria for service connection for neuroma of the left foot, to include as secondary to a service-connected disability, are not met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.310(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty to assist provisions. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). A.) Duty to Notify Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his or her 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) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). In Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) ("Pelegrini II"), the United States Court of Appeals for Veterans Claims ("Court") held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) request that the claimant provide any evidence in his or her possession that pertains to the claim. Element (4), the requirement of requesting that the claimant provide any evidence in his or her possession that pertains to the claim, was eliminated by the Secretary during the course of this appeal. See 73 Fed. Reg. 23353 (final rule eliminating fourth element notice as required under Pelegrini II, effective May 30, 2008). Thus, any error related to this element is harmless. The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), aff'd, Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007). Of particular importance, in Dingess/Hartman, the Court held that the VCAA notice must include notice that a disability rating and an effective date of the award of benefits will be assigned if service connection is awarded. In this case, VA essentially satisfied the notification requirements of the VCAA by means of letters dated in February 2009, October 2009 and March 2010. The February 2009 pre-adjudication letter informed the appellant of the types of evidence needed in order to substantiate his service connection claim on a direct basis, the division of responsibility between the appellant and VA for obtaining the required evidence, and requested that the appellant provide any information or evidence in his possession that pertained to such claims. 38 U.S.C.A. §5103(a); 38 C.F.R. § 3.159(b). The October 2009 and March 2010 letters afforded the Veteran with notice of the information necessary to substantiate a service connection claim on a secondary basis (i.e., based on an additional disability that was caused or aggravated by a service-connected disability). The letters also informed the Veteran of how VA determines the disability rating and effective date elements of a claim, thereby satisfying the Dingess/Hartman requirement. The U.S. Court of Appeals for the Federal Circuit ("Federal Circuit") has held that any error in a VCAA notice should be presumed prejudicial. The claimant bears the burden of demonstrating such error. VA then bears the burden of rebutting the presumption, by showing that the essential fairness of the adjudication has not been affected because, for example, actual knowledge by the claimant cured the notice defect, a reasonable person would have understood what was needed, or the benefits sought cannot be granted as a matter of law. Sanders v. Nicholson, 487 F.3d 881 (Fed. Cir. 2007). Here, although the Board observes the Veteran was provided with VCAA notice of how to substantiate a claim of entitlement to service connection on a secondary basis after the initial adjudication of the claim, the claim was subsequently readjudicated in an April 2010 Statement of the Case ("SOC"), which again informed him of the evidence needed to substantiate his claim. Moreover, the evidence shows that, throughout the course of his appeal, the Veteran submitted several statements demonstrating his knowledge and familiarity with the concept of secondary service connection and what was needed to establish his claim. Based on these facts, as well as the notice given, the Board finds that a reasonable person would have known what evidence was needed in order to establish entitlement to service connection on a secondary basis. Therefore, any failure in the content or timing of the notice is not prejudicial. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds. B.) Duty to Assist The Board concludes that VA's duty to assist has been satisfied. The claims file contains the Veteran's service and post-service treatment records, as well as VA examination reports dated February 2006, June 2009 and January 2013. Additionally, the claims file contains the Veteran's statements in support of his claims. The Veteran has not referenced any outstanding, available records that he wanted VA to obtain or that he felt were relevant to the claims that have not already been obtained and associated with the record. Review of the examination reports shows that, although the February 2006 VA examiner did not provide an opinion as to whether the Veteran's bilateral neuromas were secondary to a service-connected disability, the VA examiners who performed the June 2009 and January 2013 evaluations reviewed the pertinent evidence of record, elicited from the Veteran his history of service and post-service symptomatology, performed comprehensive clinical evaluations, and provided the results of such evaluations. They further provided detailed rationales for their conclusions. For these reasons, the Board concludes that the examination reports, taken as a whole, are adequate upon which to base decisions in this case. Moreover, all procedures to obtain records pertaining to the Veteran's claim have been correctly followed. In this respect, VA made an attempt to obtain updated VA treatment records for the period January to March 2009. The Court has held that where VA has constructive and actual knowledge of the availability of pertinent reports in the possession of the VA, an attempt to obtain those reports must be made. See Bell v. Derwinski, 2 Vet. App. 611 (1992). Here, although several attempts were made to obtain these records, in January 2013, VA was informed that such records were unavailable. In a January 2013 letter, the RO notified the Veteran that the records could not be obtained and requested that he submit any copies of such records in his possession. However, he failed to respond. In short, the Board has carefully considered the provisions of the VCAA in light of the record on appeal, and for the reasons expressed above, finds that the development of the claims has been consistent with the provisions of the VCAA. The appellant has been provided with every opportunity to submit evidence and argument in support of his claims, and to respond to the VCAA notice. The purpose behind the notice requirement has been satisfied because the appellant has been afforded a meaningful opportunity to participate effectively in the processing of his appealed claims. Accordingly, the Board will proceed to a decision on the merits. II. Analysis The Board has thoroughly reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). 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. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case, the claim is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Under 38 U.S.C.A. § 1154(a), VA is also required to give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. In Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007), the Federal Circuit held that "[l]ay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3), lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." (footnote omitted). However, the Court has held that "[t]he type of evidence that will suffice to demonstrate entitlement to service connection, and the determination of whether lay evidence may be competent to satisfy any necessary evidentiary hurdles, depends on the type of disability claimed." Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In order to establish a right to compensation for a present disability, a veteran must show: "(1) the existence of a present disability; (2) the in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service"- the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Alternatively, under 38 C.F.R. § 3.303(b), service connection may be awarded for a "chronic" condition when (1) a chronic disease manifests itself and is identified as such in service, or within the presumptive period under 38 C.F.R. § 3.307, and the veteran presently has the same condition; or (2) a disease manifests itself during service, or during the presumptive period, but is not identified until later, and there is a showing of continuity of related symptomatology after discharge, and medical evidence relates that symptomatology to the Veteran's present condition. Walker v. Shinseki, ___ F.3d ___, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013). Service connection may also 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) (2012). 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) (en banc). Establishing service connection on a secondary basis essentially requires evidence sufficient to 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.; see also Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran contends that his bilateral neuromas of the feet are secondary to compensatory gait and altered biomechanics, which he maintains are caused by his various service-connected orthopedic disabilities, which include disabilities of the right knee, bilateral hips, and thoracic and cervical spine. Although he has not specifically claimed the conditions are the result of any incident of service, review of the service treatment records reveals no evidence of a foot disorder during the Veteran's November 1970 service enlistment examination. While the service treatment records show that the Veteran received treatment for various injuries, including a fractured right hand in 1974, an injury to the right knee, pain in the bilateral knees, and multiple lacerations and abrasions following a 1974 motorcycle accident, there is no evidence of a foot disorder; x-rays of the legs and ankle following the accident were negative. During his January 1975 separation examination, other than a notation of a history of probable torn medial meniscus, right knee, the lower extremities were noted to be within normal limits. The post-service treatment reports of record contain no evidence that the Veteran had a foot disorder until December 2004, when private treatment records from S. Hosler, D.P.M., show that he was seen for a check of orthotics. In May 2005, he returned to the clinic requesting an injection in the area of neuromas of the bilateral feet, which, according to the Veteran, had become worse over time. The Veteran was given an injection of Depo Medrol mixed with Marcaine plain for tenderness at the neuroma site, bilaterally. In July 2005, the Veteran returned for another foot injection, complaining of bilateral pain, more severe on the right foot. At this time, he also requested that Dr. Hosler write a letter opining as to whether the neuromas could have been aggravated by his right knee disorder. In July 2005, Dr. Hosler submitted a letter, in which he stated that the Veteran had been his patient since November 2004 and opined that "the right foot and left foot neuroma symptoms are as likely as not to have been caused by [the Veteran's] right knee pathology, due to compensatory gait and alternating biomechanics in the lower extremity." He added that this "may have aggravated and caused microtrauma to the nerve resulting in his present neuromas." (emphasis added). Despite this statement, there is no further explanation to support Dr. Hosler's conclusion. The claims folder also contains private treatment records for the Veteran's service-connected right knee disorder. During a January 2006 outpatient visit to Orthopaedic and Sports Medicine center for complaints of knee pain, popping and catching, it was noted that the Veteran walked with a normal gait; despite his previous complaints to his podiatrist, there is no indication that the Veteran complained to his orthopedist of foot pain. Similarly, outpatient treatment records from this provider through October 2007 show no evidence that the Veteran ever complained of foot problems. Although these records show that he was receiving corticosteroid injections in the right knee due to degenerative arthritis, and was noted at one point to have an antalgic gait on the right side, neither the Veteran, nor the physician attributed this to a disorder of the feet. Rather, during a March 2006 visit, the Veteran reported that whenever he was on uneven ground, he had to compensate and shift his weight because he felt that his right knee would give out, so he said that he felt the doctor's assessment of his having a normal gait all the time was not accurate. Again, however, the Board notes that this gait irregularity was not attributed to any disorder of the feet. Indeed, in an August 2006 letter, the Veteran's orthopedist, Dr. M. Moses, wrote a letter to assist the Veteran in obtaining a handicapped parking permit, noting that "[d]ue to the significant nature of his osteoarthritic changes in his knee and the degenerative changes associated with this, he has great difficulty in ambulating distances, especially on uneven ground." In February 2006, the Veteran was afforded a QTC/VA feet examination. The Veteran reported that he had had a neuroma of the bilateral feet for the past 10 years, which resulted in constant pain on the soles of his feet. Upon physical examination, there were no signs of abnormal weight bearing on the soles of the feet and the Veteran's gait was noted to be within normal limits. Non-weight bearing x-rays of the right and left feet were also within normal limits. The examiner provided a diagnosis of neuroma, 3rd intermetatarsal space, bilateral feet, but did not provide an opinion as to the etiology of the condition. In November 2008, the Veteran was afforded a VA joints examination for his claim of entitlement to service connection for his right knee and back disorders. The Veteran complained of chronic back pain, which prevented him from performing house or yard work, and said that his right knee made it difficult for him to walk on uneven surfaces, as the knee sometimes gave way. Upon examination, he was noted to have a normal posture and gait without the use of assistive devices. In June 2009, the Veteran was afforded a second VA feet examination, at which time, he again reported that he had experienced foot pain for 10 years, which he attributed as the result of his service-connected right knee disorder. He reported constant stinging and aching pain and said he avoided all weight bearing. He denied the use of any assistive devices for ambulation or corrective shoes, but said he tried to buy shoes one-half size larger in order to place extra padding in the soles. While he reported having custom orthotics, he said that they actually caused him to have more foot pain. Upon physical examination, it was noted that the Veteran walked into the examination room without any assistance or assistive devices and demonstrated a normal posture and gait. The bilateral feet were negative for joint deformity, deviation, inflammation or discoloration, and there were no callus formations noted. There was normal range of motion of the toes and ankles bilaterally, but with tenderness to palpation between the third and fourth interdigital spaces at the base of the toes. Pedal pulses were normal and there was normal sensation to temperature, vibration and pinprick bilaterally. The diagnosis was Morton's neuroma between the third and fourth digits. Based on her review of the claims folder and examination of the Veteran, the examiner opined that it was less likely than not that the Veteran's bilateral Morton's neuromas were due to his service-connected chondromalacia and degenerative joint disease status-post medial meniscectomy of the right knee. In this respect, she explained that she had reviewed the medical literature, which noted that there are a number of common causes for Morton's neuroma, (though it was also noted that the condition can arise spontaneously for reasons still unknown), adding that the neuroma often occurs in response to irritation, pressure or traumatic injury to one of the digital nerves leading to the toes. The examiner further noted that a thickening of nerve tissue results as part of the body's response to the irritation or injury, and that abnormal foot movement used to compensate for bunions, hammertoes, flatfeet and other conditions can lead to irritation and development of Morton's neuroma. Pronation of the foot may cause the heads of the metatarsal bones to rotate slightly, thereby pinching the nerve running between the metatarsal heads. Chronic pressure or pinching causes the nerve sheath to enlarge, becoming increasingly squeezed, producing worsening pain over time, if not addressed. The examiner specifically noted that there was no information found per review of the medical literature to causally link chondromalacia and degenerative joint disease of the knee to the development of Morton's neuroma. She further observed that there was also no information to suggest that the Veteran's knee pathology would aggravate such a condition. In this respect, the examiner noted that the Veteran was found to have a normal gait during the examination. With regard to the July 2005 letter from Dr. Hosler, she noted that, although he opined that the Veteran's compensatory gait and altered biomechanics as a result of the right knee pathology caused the bilateral neuromas, a review of the Veteran's treatment records found that he had a normal gait when he were evaluated by the VA examiner in November of 2008, by Dr. Moses of the Orthopedic and Sports Medicine Center in January of 2006, by the QTC examiner in 2006, and by Dr. Howard, the physician who performed surgery on the Veteran's right knee in 1981. She found no evidence of abnormal gait in the Veteran's treatment records. Accordingly, the VA examiner concluded that there was no nexus between the Veteran's bilateral neuromas and his right knee disability. The Board observes that, despite the VA examiner's finding that there was no evidence of record that the Veteran had an antalgic gait, as noted above, private treatment records show that his right-sided antalgic gait was attributed to his right knee disability. Subsequent private treatment records from M. Moses, M.D., of Orthopaedic and Sports Medicine, dated September 2009, show that the Veteran was seen for complaints of right hip, knee and back pain. He also reported right foot pain, which he again attributed to his altered gait. Upon examination, the Veteran displayed an antalgic gait on the right side with pain over the medial joint line of the right knee and limited and painful range of motion of the right hip. Examination of the right ankle and foot revealed full and painless active and passive range of motion with the exception of the second and third metatarsals. The right knee also showed a fixed 10 degree varus deformity, while the left knee was in five degrees of valgus deformity. It was also noted that he had a scoliotic curve in the thoracic and lumbar spine, which the examiner said severely affected his quality of life. Dr. Moses opined that these limitations were a direct consequence of the Veteran's injuries sustained in service and led to subsequent right foot and right hip problems due to his chronically altered gait. In December 2009, the Veteran was afforded another QTC/VA examination for his right hip, right knee and thoracolumbar spine. Although the clinician noted that the Veteran walked with an antalgic, unsteady gait, he observed that an examination of the feet revealed no signs of abnormal weight bearing or breakdown, callosities or any unusual shoe wear pattern. It was further noted that he did not require any assistive devices for ambulation. In October 2011, the Veteran was afforded a QTC/VA examination for claims of a chronic neck and spine disorder. At that time, although the examiner did not evaluate or examination the Veteran's feet, she specifically noted that he did not use or require an assistive device for ambulation and his posture and gait were within normal limits. In January 2013, the Veteran was afforded another VA feet examination, performed by the clinician who had performed the November 2008 joints examination. At that time, the examiner was asked to opine as to whether the Veteran's bilateral foot disorder had either been caused or aggravated by any of his service-connected orthopedic disabilities, including his scoliosis and degenerative changes of the thoracic spine, his intervertebral disc syndrome of the cervical spine, his right knee degenerative joint disease and post-meniscectomy right hip sprain, or his left hip degenerative joint disease. During the evaluation, the Veteran described experiencing a constant, aching pain, worse with prolonged standing or walking. The Veteran denied the use of any assistive devices for ambulation. The examiner diagnosed the Veteran with Morton's neuroma and metatarsalgia bilaterally; there were no other foot disorders or injuries noted. The examiner concluded that the Veteran's condition was less likely than not proximately due to, or the result of any service-connected disorder. In this respect, she explained that neuromas of the feet can be caused in response to irritation, pressure or traumatic injury to one of the digital nerves leading to the toes. The nerve tissue can enlarge or thicken in response to the irritation or injury, resulting in the development of a neuroma. This causes pain and discomfort in the feet, as described by the Veteran. She further noted that, during the examination, the Veteran's gait was observed to be normal upon ambulation into the office prior to the examination. After the physical examination of the feet, however, he walked with the weight distributed over the lateral and posterior aspect of the feet, which she attributed to pain in the feet caused by the examination itself. Moreover, she observed that review of the records in the claims folder indicated that the Veteran had been noted to have a normal gait by several clinicians, including Dr. Howard in 1981, the QTC examiner in 2006, by the VA examiner herself during the November 2008 joints examination, and by the VA examiner in 2009. She further observed that it was notable that the Veteran had significant degenerative changes of the right knee, as well as significant pathology of the spine and sacroiliac joints, resulting in hip pain. However, review of the available medical records over the course of the previous 30 years did not indicate consistent gait abnormalities so as to result in pressure or traumatic injury to the nerves in the feet. As observed during the VA examination, any gait abnormalities the Veteran had were more likely due to the pain in his feet due to the neuromas. The examiner therefore concluded, taking all factors into consideration, that it was less likely than not that the Veteran's foot neuromas were caused or aggravated by the service-connected conditions of the cervical spine, thoracic spine, right knee, or bilateral hips. She further noted that, while she had considered the opinion of the Veteran's private podiatrist in formulating her opinion, she noted that he did not have access to the Veteran's claims folder, which she noted contained "a breadth of medical records spanning decades of the Veteran's medical evaluation and treatment." III. Conclusion In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). The Board also has the responsibility to weigh the evidence, including the medical evidence, to determine where to give credit and where to withhold the same, and in so doing, the Board may accept one medical opinion and reject others, provided it offers an adequate basis for so doing. See Evans v. West, 12 Vet. App. 22, 30 (1998); Owens v. Brown, 7 Vet. App. 429, 433 (1995). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Based on a review of the complete evidence of record, the Board concludes that the probative evidence is against the Veteran's claim of entitlement to service connection for neuromas of the bilateral feet. In this regard, as noted above, the Board has considered whether service connection is warranted either on a direct or secondary basis. The Board notes that, whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). With regard to granting service connection on a direct basis, as noted above, there is no evidence, either in the form of statements from the Veteran, or medical evidence in the service treatment records, to show that the Veteran was found to have a foot disorder at anytime during active military service. In addition, as no examiners have linked his current bilateral neuromas to any direct incident of service, service connection on a direct basis is denied. With regard to granting service connection on a secondary basis, the Board has considered all of the available medical evidence of record, including the opinions from the Veteran's private physicians. However, after taking all of the evidence into consideration, the Board finds the most probative evidence to be the opinions of the June 2009 and January 2013 VA examiners, who, after thoroughly reviewing the evidence of record, including the Veteran's service and post-service treatment records since 1981, as well as the medical literature on the causes of Morton's neuroma, opined that it was less likely than not that the Veteran's current neuromas of the bilateral feet were related to a service-connected disability, including his right knee degenerative joint disease. In arriving at their conclusions, the examiners provided well-reasoned and fully-detailed reports explaining the reasons and bases for the opinions. Significantly, the January 2013 examiner noted that, even after 30 years, there was no evidence that the Veteran had consistent gait abnormalities. With regard to the opinion by the Veteran's private podiatrist, Dr. Hosler, who stated that it was as likely as not that his right and left foot neuroma symptoms were caused by his right knee disorder, noting that a compensatory gait and lower extremity alternating biomechanics "may have aggravated and caused microtrauma to the nerve," (emphasis added) resulting in the present condition, the Board notes the Court has held that medical evidence that is speculative, general or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). Here, it is obvious that the statement provided by the Veteran's podiatrist was equivocal, in that he not only said a compensatory gait may have aggravated/caused trauma to the nerves, but he also failed to provide any reasons or basis for his statement. There is also no indication that he ever reviewed any of the Veteran's treatment reports of record, which, contrary to his assertion, showed that the Veteran generally displayed a normal gait. The Board also discounts the opinion from Dr. Moses for the same reason. Although he opined that the Veteran's injuries sustained during military service led to right foot problems and a chronically altered gait, he specifically noted that the Veteran had right and left knee deformities, as well as a scoliotic curve of the thoracic and lumbar spine. Yet, he failed to provide any information as to why these conditions would result in a nerve injury between the toes. In August 2006, three years prior to making this statement, Dr. Moses specifically wrote that the Veteran had difficulty ambulating due to his osteoarthritic and degenerative changes in his right knee. As such, the Board accords less probative weight to the opinions of Drs. Holser and Moses. In contrast, the VA examiners explained the medically-known causes of neuromas, and the examiner who performed the June 2009 examination specifically noted that there was no information in the medical literature to causally link chondromalacia and degenerative joint disease of the knee to the development of Morton's neuroma. As such, the Board finds the opinions by the VA examiners outweigh the statements by the Veteran's private physicians. In addition to the medical evidence, the Board has also considered the statements of the Veteran as to the cause of his bilateral foot disorders. In this regard, the Court has held that a claimant is competent to attest to factual matters of which he or she has first-hand knowledge. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, although the Veteran is competent to report what comes to him through his senses, there is no evidence that he has medical knowledge or training that would permit him either to diagnose, or determine the etiology of a complex disorder of the nerves, such as Morton's neuroma. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (explaining in footnote 4 that a veteran is competent to provide a diagnosis of a simple condition such as a broken leg, but not competent to provide evidence as to more complex medical questions). As such, although the Board acknowledges the Veteran's belief that his current disease is the result of a service-connected disorder, his statements in this regard are not deemed competent. Accordingly, the Board concludes that the most probative evidence of record is against the Veteran's claims of service connection for neuromas of the right and left feet. In arriving at the decision to deny the claim, the Board has considered the applicability of the "benefit-of-the-doubt" rule. However, as there is not an approximate balance of evidence, that rule is not applicable in this case. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for neuroma of the right foot, to include as secondary to a service-connected disability, is denied. Entitlement to service connection for neuroma of the left foot, to include as secondary to a service-connected disability, is denied. ____________________________________________ S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs