Citation Nr: 1314588 Decision Date: 05/02/13 Archive Date: 05/15/13 DOCKET NO. 07-29 115 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to a compensable rating for a scar, plantar surface right foot, prior to July 23, 2009. 2. Entitlement to an increased rating in excess of 10 percent for a scar, plantar surface right foot, from July 23, 2009. 3. Entitlement to service connection for a right knee condition, claimed as secondary to service-connected scar, plantar surface right foot. REPRESENTATION Appellant represented by: Kenneth LaVan, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Catherine Cykowski, Counsel INTRODUCTION The Veteran had active duty service from January 1975 to May 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal from December 2006 and December 2009 rating decisions by the Department of Veterans' Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In September 2008, the Veteran testified at a hearing before the undersigned Veterans Law Judge. The Board previously remanded this matter in March 2009 and June 2010. The development ordered in the March 2009 remand included affording the Veteran a VA examination to ascertain the severity of his right foot scar and to obtain an opinion regarding the etiology of a current right knee disability. The development ordered in the June 2010 remand included affording the Veteran an examination of the right foot scar to determine whether there is nerve damage or functional impairment associated with the scar and obtaining a medical opinion as to whether the Veteran's right knee disability was aggravated by the right foot scar. The March 2009 and June 2010 remand directives have been satisfied. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. For the period prior to July 23, 2009, the Veteran's scar, plantar surface right foot was painful on examination but was not unstable, was less than 6 inches in area and did not cause any functional loss. 2. For the period after July 23, 2009, the Veteran's scar, plantar surface, right foot did not result in functional loss. 3. The competent, credible, and probative evidence of record does not demonstrate that a right knee disability is proximately due to or the result of a service connected disability, including aggravation by a service connected disability. CONCLUSIONS OF LAW 1. Prior to July 23, 2009, the criteria for a 10 percent rating for a scar, plantar surface of the right foot, are met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.118, Diagnostic Codes 7801-7804 (2007). 2. From July 23, 2009, the criteria for a rating in excess of 10 percent for a scar, plantar surface of the right foot, are not met. 38 U.S.C.A. §§ 1155, 5103, 5103A (West 2002); 38 C.F.R. §§ 3.159, 4.118, Diagnostic Codes 7801-7804 (2007). 3. A right knee disorder is not proximately due to, or aggravated by, a service-connected disability. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist As provided for by VCAA, VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100 , 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.102 , 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any 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); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from 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 in accordance with 38 C.F.R. § 3.159(b)(1). This notice must be provided prior to an initial unfavorable decision on a claim by the AOJ, in this case the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that, upon receipt of an application for a service-connection claim, 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating, or is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Here, the VCAA duty to notify was satisfied by way of a letter dated in October 2006, prior to the initial adjudication of the claims. The October 2006 letter informed the Veteran of what evidence was required to substantiate his claims and of the Veteran's and VA's respective duties for obtaining evidence. This letter also informed the Veteran of how disability ratings and effective dates are determined. VA also has a duty to assist the Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A ; 38 C.F.R. § 3.159. In this case, the record indicates that the RO obtained all information relevant to the Veteran's claim. The record includes service treatment records and post-service private and VA treatment records. The Veteran has not identified any outstanding evidence that is pertinent to these claims. Moreover, the Veteran underwent adequate and probative VA medical examinations. 38 U.S.C.A. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran had VA examinations of his right foot scar in November 2006, July 2009, December 2010 and March 2012. The Veteran had VA examinations of his right knee in November 2006 and December 2010. The Board finds that the VA opinions obtained in this case are adequate, as the opinions are predicated on a full reading of the private and VA medical records in the Veteran's claims file. The VA nexus opinions regarding the Veteran's right knee disability considered all of the pertinent evidence of record, to include service treatment records, VA treatment records, comprehensive physical examinations, and the statements of the Veteran, and provide a complete rationale for the opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the issues on appeal has been met. 38 C.F.R. § 3.159(c)(4). For the reasons set forth above, the Board finds that VA has complied with the VCAA's notification and assistance requirements. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Significantly, neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist the Veteran in the development of the claim. Smith v. Gober, 14 Vet. App. 227(2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Analysis of Claims Disability Ratings - Law and Regulations Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Generally, the degrees of disability specified are considered adequate to compensate for considerable loss of working time from exacerbations or illnesses proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes. 38 C.F.R. § 4.27 (2012). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability more closely approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the policy of the VA to administer the law under a broad interpretation, consistent with the facts in each case, with all reasonable doubt to be resolved in favor of the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. After careful consideration of the evidence, any reasonable doubt remaining is resolved in the claimant's favor. 38 C.F.R. § 4.3. In order to evaluate the level of disability and any changes in severity, it is necessary to consider the complete medical history of the disability. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating was filed until the final decision is made. Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board has reviewed all of the evidence in the claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate, and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. Rating Criteria for Scars The Veteran's scar, plantar surface of right foot, is rated pursuant to 38 C.F.R. § 4.118, Diagnostic Code 7804. A non-compensable (0 percent) rating was assigned prior to July 23, 2009, and a 10 percent rating has been in effect since July 23, 2009. The Board notes that, as of October 23, 2008, revised provisions for evaluating scars were enacted; however, this new regulation indicates that the revised provisions are applicable only to claims received on or after October 23, 2008. The Veteran's claim for an increased rating was filed in October 2006 prior to the effective date of the revised criteria; accordingly, these revisions do not apply to the present case. 73 Fed. Reg. 54708 (Sept. 23. 2008). Rather, the Veteran's appeal for a higher initial rating for the service-connected right foot scar will be considered under the criteria effective as of the date of the 2006 claim. Under 38 C.F.R. § 4.118, Diagnostic Code 7801 (2007), scars other than on the head, face, or neck that are deep or cause limited motion are to be evaluated as 10 percent disabling for areas exceeding 6 square inches, 20 percent disabling for areas exceeding 12 square inches, 30 percent disabling for areas exceeding 72 square inches, and 40 percent disabling for areas exceeding 144 square inches. Notes following the rating criteria explain (1) scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of the extremities or trunk, will be rated separately and combined in accordance with 38 C.F.R. § 4.25, and (2) a deep scar is one associated with underlying soft tissue damage. 38 C.F.R. § 4.118 (2007). DC 7802 provides that scars other than head, face, or neck that are superficial and do not cause limited motion will be rated as 10 percent disabling for areas of 144 square inches or greater. Notes following the rating criteria explain (1) scars in widely separated areas, as on two or more extremities or on anterior and posterior surfaces of the extremities or trunk, will be rated separately and combined in accordance with 38 C.F.R. § 4.25, and (2) a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. Part 4. DC 7803 provides that unstable superficial scars are evaluated as 10 percent disabling. Note (1) following indicates that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) indicates that a superficial scar is one not associated with underlying soft tissue damage. 38 C.F.R. § 4.118 (2007). Diagnostic Code 7804, provides that superficial scars that are painful on examination are rated as 10 percent disabling. Note (1) following states that a superficial scar is one not associated with underlying soft tissue damage. Note (2) states that a 10 percent evaluation will be assigned for a scar on the tip of a finger or toe even though amputation of the part would not warrant a compensable evaluation (See 38 C.F.R. § 4.68 of this part on the amputation rule). Diagnostic Code 7805 directs that other scars shall be rated on the limitation of function of the affected part. 38 C.F.R. § 4.118. Rating for Scar, Plantar Surface of Right Foot Prior to July 23, 2009 Upon VA examination in November 2006, the Veteran reported that he had an injury of his right foot in service. He reported a glass cut to the plantar mid foot or sole surface of the foot. The wound was irrigated and sutured. The Veteran reported that he used occasional magnesium sulfate or Epsom salt soaks and occasionally took medication for foot pain. The Veteran reported pain on the plantar surface of the foot and reported that he felt like "something is still in there." On physical examination, the examiner noted a well-healed surgical scar. It was 3.5 centimeters by 5 centimeters and was depressed approximately one to two millimeters. There was no palpable area of abnormality and no induration. The VA examiner indicated that there did not appear to be adherence to the underlying tissue of the scar. The VA examiner noted that even a slight touch of the scar caused the Veteran to wince. The VA examiner noted that there was limitation of motion of the lateral three toes in flexion and extension. The VA examiner indicated that this was not caused by the scar but was caused by the underlying probable nerve injury to the scar. The VA examiner indicated that there was no objective evidence that the Veteran was extensively favoring the right foot by walking on the lateral aspect consistently. The VA examiner noted that the Veteran did not have significant callus formation on the sole of the right foot. The VA examiner indicated that, although the Veteran did have sole wear, the shoes were old and well-worn throughout. The VA examiner indicated that the Veteran had weakness, especially in the plantar flexors of the second through fourth toes, as evaluated by the Gainesville Podiatry Clinic. The VA examiner opined that the second toe is normal. The VA examiner stated that the third and fourth toes were certainly more weak than the fifth toe and possibly half of the second toe could be involved. The VA examiner indicated that that would be due to the laceration or involvement of the nerve, which also subserves approximately 0.25 to 0.50 of the lateral aspect of the second toe. The VA examiner indicated that he could not make the differentiation himself. A report of a VA podiatry consultation dated in February 2009 reflects that the Veteran was referred by urgent care for right foot pain. He had a note from a private doctor showing an MRI of the right foot with no foreign body or neuroma. On examination, the podiatrist noted hypersensitive extremely painful scar tissue of the right arch. In light of the findings shown on the November 2006 and July 2009 VA examination, the Board remanded the increased rating claim to obtain an opinion as to whether there is nerve damage associated with the service-connected scar and, if so, the extent of any nerve damage. A December 2010 VA examination report addressed the question of whether there was nerve damage related to the service-connected scar of the right foot. The VA examiner diagnosed peripheral neuropathy of the right foot. The VA examiner opined that the peripheral neuropathy of the right foot is not caused by or a result of the plantar laceration of the right foot. The VA examiner reasoned that the distribution of numbness was in the dorsal aspect of the right foot, and the Veteran's laceration is in the plantar aspect. The VA examiner opined that it is not anatomically possible for the Veteran's service-connected right foot condition to give him numbness in the superficial peroneal distribution. The VA examiner indicated that the opinion was based upon the current anatomical sensory mapping literature. Applying the rating criteria to the foregoing evidence, the Board finds that a 10 percent rating, but no higher, is warranted for a scar of the plantar surface right foot prior to July 23, 2009. The evidence includes the 2006 VA examination, which reflects the Veteran's report of pain on the plantar surface of the right foot. A 10 percent rating under Diagnostic Code 7084 is warranted. The Board finds that weight of the lay and medical evidence does not demonstrate that the criteria for a rating in excess of 10 percent are met. A higher rating is not assignable under DC 7801, as the scar does not exceed 12 inches in area. A higher rating is not warranted based upon limitation of function of the right foot. In this regard, the VA examiner indicated that the Veteran had a normal stance and that there were no corns or calluses on the right foot indicative of mal-use of the right foot when walking. Some limitation of motion of the toes in flexion and extension was noted, but the examiner did not indicate any limitation of function due to the limitation of motion of the toes. In addition, while the VA examiner noted that there was weakness of the second through fourth toes, the VA examiner indicated that he could not make a differentiation regarding nerve involvement. The December 2010 VA examination report clarified that there is no nerve damage as a result of the scar. Thus, the weight of evidence of record for the time period prior to July 23, 2009 does not establish limitation of function of the right foot associated with scar on the plantar surface of the right foot. Accordingly, the Board concludes that a higher evaluation is not warranted for limitation of function. As noted above, the December 2010 VA examiner concluded that peripheral neuropathy of the right foot with associated symptoms are not caused by or a result of the plantar laceration of the right foot. Therefore, the rating criteria pertaining to neurological conditions are not applicable in this case. In summary, for the period prior to July 23, 2009, the Board concludes that a 10 percent rating, but no higher, is warranted for a scar on the plantar surface of the right foot, pursuant to Diagnostic Code 7804. Rating for Scar, Plantar Surface of Right Foot From July 23, 2009 Upon VA examination in July 2009, the Veteran reported decreased sensation on the lateral aspect of the right foot. The Veteran reported a history of sustaining a plantar laceration of the midfoot when he stepped on a broken bottle during service in 1978. The VA examiner noted that the Veteran's laceration was treated with debridement and suturing of the right plantar laceration. The Veteran reported that he currently did not have treatment for his right foot condition. The Veteran reported that he had been treated with orthotics with a central cutout but could not tolerate that treatment. On physical examination, the maximum width of the scar was 2 centimeters, and the maximum length of the scar was 2 centimeters. The VA examiner noted that the scar was painful. The scar was deep but had no other disabling effects. The VA examiner noted that the scar showed signs of edema or keloid formation. The scar was adherent to underlying plantar fascia, moderately painful to palpation. There was no evidence of ulcerative breakdown. There was normal pigmentation. The VA examiner diagnosed painful plantar scar, right foot. A June 2009 VA orthopedic treatment note reflects that the Veteran reported numbness in his right foot since stepping on a broken bottle during service. Physical examination revealed decreased sensation on the bottom of the right foot only. A July 2009 VA neurology consultation reflects the Veteran presented with a complaint of numbness and pain in his right foot and right forefoot since he stepped on glass while in service. The Veteran reported severe pain and tenderness under the scar in his midfoot and reported that he was unable to fully flex his toes on the right. The Veteran reported that he had several nerve conduction studies in the past and was apprehensive of taking the test. A nerve conduction test was started after obtaining verbal consent, but it was stopped because the Veteran was unable to tolerate it. The Veteran had a VA examination in December 2010. The Veteran reported numbness and pain in the right forefoot since he stepped on glass in service. The Veteran reported severe tenderness and pain under the scar in his midfoot. He reported that he was unable to fully flex his toes on the right. The VA examiner noted that the Veteran's painful scar on the right foot would give him difficulty with standing for protracted periods or walking long distances. The VA examiner noted a mild antalgic gait of the right lower extremity secondary to a painful plantar scar. The VA examiner diagnosed peripheral neuropathy of the right foot. The VA examiner opined that the peripheral neuropathy of the right foot is not caused by or a result of the plantar laceration of the right foot. The VA examiner reasoned that the distribution of numbness was in the dorsal aspect of the right foot, and the Veteran's laceration is in the plantar aspect. The VA examiner opined that it is not anatomically possible for the Veteran's service-connected right foot condition to give him numbness in the superficial peroneal distribution. The VA examiner indicated that the opinion was based upon the current anatomical sensory mapping literature. The Veteran had a VA examination in March 2012. The Veteran reported that the scar was tender. The VA examiner indicated that the scar was not unstable. The VA examiner indicated that the scar did not result in limitation of function. The Board finds that the weight of the lay and medical evidence does not demonstrate that the criteria for a rating in excess of 10 percent for the scar, plantar surface of the right foot have not been met at any point in the appeal period. The criteria for a 20 percent rating under Diagnostic Code 7801 are not met, as the scar does not exceed 12 inches in area. The 2010 VA examination indicated that peripheral neuropathy of the right foot is not related to the right foot plantar scar; accordingly, a higher rating is not warranted for nerve impairment. The weight of the evidence does not demonstrate that a higher rating is assignable based upon functional impairment. The December 2010 VA examination indicates the functional impairment associated with the scar is a mild antalgic gait due to the pain caused by the scar. The 10 percent rating assigned under DC 7804 contemplates the pain associated with the scar. The evidence does not show a separately ratable impairment, such as a right foot disability, that is associated with the Veteran's antalgic gait. Accordingly, the Board finds that a rating in excess of 10 percent is not assignable under Diagnostic Code 5284 based upon functional impairment of the right foot due to the right foot scar. The weight of the evidence does not demonstrate that there is any other applicable Diagnostic Code. For these reasons, the Board concludes that there is a preponderance of the evidence against the claim for a rating in excess of 10 percent for a scar, plantar surface of the right foot. Accordingly, as the preponderance of the evidence is against the claim, the appeal must be denied. 38 C.F.R. §§ 4.3, 4.7. Extraschedular considerations In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). The threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate. Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability. Thun v. Peake, 22 Vet. App. 111 (2008). Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms." 38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, the Board finds that the schedular rating criteria contemplate the Veteran's service-connected scar, plantar surface of the right foot. The Diagnostic Codes (7801-7805), 38 C.F.R. § 4.118 , considered for rating the scar includes ratings based on any limitation of motion, square area of coverage by the scar, scar findings such as instability or painfulness, and limitation of function. The Veteran has described no other symptoms of disability that are related to his service-connected right foot scar. As discussed above, the complaints such as numbness of the foot have been related to peripheral neuropathy which is not a result of the service-connected scar. Because the schedular rating criteria is adequate to rate the scar, there is no exceptional or unusual disability picture to render impractical the application of the regular schedular standards. For these reasons, the Board finds that the criteria for referral for extraschedular rating have not been met. 38 C.F.R. § 3.321(b)(1). Service Connection for Right Knee Condition Service connection may be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). "Aggravation" is defined for this purpose as a chronic, permanent worsening of the underlying condition, beyond its natural progression, versus a temporary flare-up of symptoms. Id. To prevail on the issue of secondary service causation, generally, the record must show (1) medical evidence of a current disability, (2) a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Effective from October 10, 2006, 38 C.F.R. § 3.310 was amended. See 71 Fed. Reg. 52,744 (2006). The new regulation appears to place additional evidentiary burdens on claimants seeking service connection based on aggravation, specifically in terms of requiring the establishment of a baseline level of disability for the non-service-connected condition prior to the claimed aggravation. The October 2006 claim was received after the effective date of the revision to 38 C.F.R. § 3.310 and therefore the amended version of 38 C.F.R. § 3.310 is applicable to the Veteran's claim. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Veteran asserts that his current right knee disability is either caused or aggravated by service-connected scar on the plantar surface of the right foot. The Veteran had active duty service from January 1975 to May 1980. Service treatment records do not reflect complaints or diagnoses regarding the right knee. In written statements in support of his claim, the Veteran has asserted that he limps on his right foot because of his service-connected right foot scar. The Veteran asserts that this has caused damage to the right knee. A January 1983 rating decision granted service connection for a scar on the plantar surface of the right foot from September 1982. An August 2005 VA physical therapy record noted that the Veteran appeared to be modifying his gait due to an area of hypersensitivity on the sole of his right foot. The record noted that there did not appear to be an orthopedic component to the deviation presented. A physical therapist noted that the gait deviation may be causing his knee, hip and back complaints, but the deviation was not a dramatic difference. A VA radiology report dated in September 2005 reflects that the Veteran reported right knee pain for one week. An x-ray noted an impression of early osteoarthritis. A VA pain clinic treatment record dated in December 2005 reflects that the Veteran reported right knee pain secondary to a right foot injury during active service. A VA orthopedic treatment record dated in March 2006 reflects that the Veteran reported right knee pain. He reported that his old foot injury was causing knee problems. The Veteran had a VA examination in November 2006. The Veteran reported chronic right knee pain due to an injury to the plantar surface of his right foot. The VA examiner diagnosed degenerative joint disease of the right knee with possible partial tear of the ACL on MRI. The VA examiner noted that the Veteran never had evaluation of anything concerning his knee within the two years of service after injuring his foot. The VA examiner further noted that there were no complaints when he was leaving service, and the Veteran did not seek care until 2002, approximately 24 years after service. The VA examiner noted that the conditions noted on MRI and x-ray, as well as medical evaluations clinically of the Veteran's knee by several individuals, are consistent more with injury or surgery pattern than anything else. The VA examiner indicated that, although the Veteran vehemently denied that he ever had surgery, there appeared to be two or three small punctate areas that could be scars and would be appropriate placement for arthroscopy if the Veteran did have arthroscopy. The VA examiner stated that, if the Veteran was having such severe displacement of the lower extremity and low back, the examiner would expect to see initially significant complaints about the lateral ankle area first before the knee problem with walking as the Veteran described it on the lateral edge of the right foot. The VA examiner concluded that, based on the type of injury which looks like an injury to the knee as opposed to gradual wear and tear, and based on the lack of ankle problems prior to the knee problem, it is less likely than not that the knee condition in the right knee is secondary to a 28-year-old puncture wound to the sole of the right foot. A private treatment record dated in September 2007 reflects that a physician diagnosed meniscal pathology of the right knee. The physician stated that, " It is certainly possible and even likely that the chronic gait abnormality from the Veteran's foot injury has adversely affected his right knee." The Veteran had a VA examination in December 2010. The VA examiner opined that osteoarthritis of the right knee is not permanently aggravated by the laceration of the right foot with painful plantar scar. The VA examiner explained that the Veteran's current osteoarthritis of the right knee is a normal expected aging outcome, stand alone entity, neither adjunct nor aggravated by the Veteran's service-connected right foot condition. The VA examiner indicated that the opinion was based upon the normal expected aging outcome. In order to establish service connection on a secondary basis, there must be medical evidence of a nexus (either on a direct basis or due to aggravation) between a service-connected disability and the disability at issue. Wallin, supra; Reiber, supra. The weight of the evidence of record is against a finding that such a relationship exists between the Veteran's service-connected right foot scar and his current right knee disability. The private physician's statement dated in September 2007 provides support for the claim. The VA examination in November 2006 found that a current right knee disability is less likely than not secondary to a right foot scar. The December 2010 VA examination concluded that the Veteran's right knee disability is related to normal aging and is not aggravated by the service-connected right foot condition. 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, 470-471 (1993). When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). The factors for assessing the probative value of a medical opinion include the physician's access to the claims folder and the Veteran's history, and the thoroughness and detail of the opinion. Prejean v. West, 13 Vet. App. 444 (2000). The weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Sklar v. Brown, 5 Vet. App. 140, 146 (1993); Guerrieri, 4 Vet. App. at 470-71. After review of the record, the Board finds that the preponderance of the competent, credible and probative evidence is against the claim of service connection for a right knee disability, claimed as secondary to the service-connected scar on the plantar surface of the right foot. The Veteran has limited his claim of service connection on the basis that the claimed disability is secondary to, either by causation or aggravation, the service-connected right foot scar. Neither the Veteran nor his representative have asserted that the right knee disability had its onset in service or is otherwise related to active service. As such, the Board will consider the claim on a secondary basis only. The Board finds the opinion of the private physician dated in September 2007 less probative than the opinions of the 2006 and 2010 VA examiners. The VA medical opinions were more through and detailed and were based upon a review of the entire claims file, including the service medical records. The September 2007 opinion by the private physician does not indicate that any medical records or the claims file were reviewed in rendering the decision. The physician indicated that a relationship between the right foot scar and the claimed right knee disability is "certainly possible and even likely." This opinion is speculative and was not stated to the degree of certainty required to support a claim of service connection. See Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinions that are speculative, general, or inconclusive in nature cannot support a claim). Additionally, the September 2007 private opinion does not address or establish the degree of aggravation of the claimed disability. As such, the opinion does not provide a legal basis for a grant of service connection based on secondary service connection. 38 C.F.R. § 3.310 (2012). The Board finds that the VA opinions expressed in 2006 and 2010 are more probative than the private statement of dated in September 2007, and that the weight of the competent and probative evidence demonstrates that the right knee disability is not proximately due to or aggravated by the service-connected right foot scar. As noted above, the VA examiners reviewed the claims file and provided a rationale for the opinions expressed. The November 2006 VA examiner indicated that, if the Veteran had such severe displacement of the right foot, he would expect to see complaints regarding the right ankle first. The December 2010 VA examiner concluded that the Veteran's right knee disability was not due to or aggravated by the right foot condition and is related to aging. As such, the Board finds that the VA opinions outweigh the private opinion, and service connection for a right knee disability, claimed as secondary to a plantar scar of the right foot is not warranted. The Board has considered the Veteran's lay statements. In certain circumstances, lay evidence may be sufficient to establish a medical diagnosis or nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In addressing lay evidence and determining its probative value, if any, attention is directed to both competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). See Layno v. Brown, 6 Vet. App. 465, 469 (1994). In terms of competency, lay evidence has been found to be competent with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007) (concerning varicose veins); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (a dislocated shoulder); Charles v. Principi, 16 Vet. App. 370, 374 (2002) (tinnitus); Falzone v. Brown, 8 Vet. App. 398, 405 (1995) (flatfoot). That notwithstanding, a Veteran is not competent to provide evidence as to more complex medical questions and, specifically, is not competent to provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). At the Board hearing, the Veteran testified that he has walked with a limp since his right foot injury. The Veteran is competent to testify to his observable symptoms. The Board finds credible the Veteran's assertions of symptomatology and disability manifestations, and he is competent to provide such evidence. See Layno, supra. The Veteran, however, is not competent to provide evidence regarding causation in a medically complex questions such those herein, which necessitate medical expertise to determine. Duenas v. Principi, 18 Vet. App. 512, 520 (2004). As a result, the Board finds the weight of the evidence is against a finding that the current right knee disability is caused or aggravated by the service-connected right foot scar. For the reasons set forth above, the Board finds that there is a preponderance of the evidence against the claim for service connection for a right knee disability, claimed as secondary to service-connected scar, plantar surface of the right foot. As there is a preponderance of the evidence against the claim, reasonable doubt may not be resolved in the Veteran's favor. 38 U.S.C.A. § 5107. ORDER Prior to July 23, 2009, a 10 percent rating is granted for scar, plantar surface of the right foot, subject to regulations governing the payment of monetary benefits. From July 23, 2009, a rating in excess of 10 percent for scar, plantar surface of the right foot, is denied. Service connection for a right knee condition is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs