Citation Nr: 1316726 Decision Date: 05/22/13 Archive Date: 05/31/13 DOCKET NO. 04-01 643 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manila, the Republic of the Philippines THE ISSUES 1. Entitlement to service connection for coronary artery disease, to include as secondary to hypertension. 2. Entitlement to service connection for hypertension. 3. Entitlement to service connection for residuals of a contusion of the right distal thigh (also claimed as right thigh pain). 4. Entitlement to a rating in excess of 10 percent for bilateral tinea pedis. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Davitian, Counsel INTRODUCTION The veteran served on active duty from December 1972 to March 1977. This matter is before the Board of Veterans' Appeals (Board) from rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Manila, the Republic of the Philippines. In a December 2002 decision, the RO declined to reopen a claim for service connection for a disability manifested by chest pain. On appeal in July 2006, the Board noted that neither the December 2002 rating decision nor the Veteran's timely notice of disagreement (NOD) included a specific claim for service connection for coronary artery disease (CAD). However, the claims file contained such a diagnosis, and this condition had been addressed in a November 2003 statement of the case (SOC). The Veteran subsequently filed a timely substantive appeal with respect to this issue. Therefore, the Board determined that the claim for service connection for CAD was a new claim. See Ephraim v. Brown, 82 F.3d 399, 401 (Fed. Cir. 1996) (where a prior claim for service connection has been denied, and a current claim contains a different diagnosis, a new decision on the merits is required). The Board remanded the case for the purpose of providing the Veteran with proper notice and obtaining a cardiology examination. The RO thereafter provided a supplemental statement of the case (SSOC) in August 2007. In rating decisions dated July 2005 and December 2005, the RO denied service connection for hypertension and declined to reopen a claim for service connection for contusion, right distal thigh (also claimed as right thigh pain). The December 2005 decision also denied a rating in excess of 10 percent for tinea pedis. In a January 2006 correspondence, the Veteran indicated that he no longer wished to appeal the hypertension issue. However, the veteran filed a NOD with respect to all three issues in February 2006. The RO provided an SOC in May 2006, and the Veteran filed a substantive appeal that same month. The RO provided SSOCs in June and July 2006. In April 2008, the Board reopened the Veteran's claim for service connection for contusion, right distal thigh. The Board remanded the claims for additional development. A November 2009 SSOC denied the claims. The service connection issues are now before the Board for final appellate consideration. The Board is aware that the April 2008 remand addressed the increased evaluation issue on appeal as entitlement to a rating in excess of 10 percent for bilateral tinea pedis, from September 4, 1996. In this regard, the Board points out that the rating decision on appeal is not the 2002 rating decision that granted service connection for tinea pedis, evaluated as 10 percent disabling, effective September 4, 1996. Rather, the rating decision on appeal is the December 2005 rating decision that was based on a September 2005 claim for an increased evaluation. As a result, the Board has recharacterized the increased evaluation issue as listed on the title page of this decision. The issue of entitlement to a rating in excess of 10 percent for bilateral tinea pedis is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record that the Veteran's CAD is related to active duty, or that it was proximately caused or aggravated by a service-connected disability. 2. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record that the Veteran's hypertension is related to active duty. 3. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record that the Veteran has residuals of a contusion of the right distal thigh. CONCLUSIONS OF LAW 1. CAD was not incurred in or aggravated by active service, may not be presumed to have been so incurred or aggravated, and was not incurred or aggravated as a result of a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310(a) (2012). 2. Hypertension was not incurred in or aggravated by active service, and may not be presumed to have been so incurred or aggravated. 38 U.S.C.A. §§ 1110, 1112, 1131, 1133, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 3. Residuals of a contusion of the right distal thigh (also claimed as right thigh pain) were not incurred or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Notice and Assistance VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided in a September 2008 letter. Thereafter, the claims on appeal were readjudicated in a November 2009 SSOC. Accordingly, the duty to notify has been fulfilled. With regard to the duty to assist, the claim's file contains the Veteran's service treatment records, VA and private medical records, the transcript of a July 2004 hearing before a Decision Review Officer, and statements from the Veteran and a witness. The Board has carefully reviewed the record and concludes that there has been no identification of further available evidence not already of record. VA examinations with respect to the Veteran's CAD and hypertension were conducted in April 2004 and September 2006. VA conducted an examination with respect to the Veteran's thigh in January 2009. VA obtained a VA medical expert opinion in November 2011. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the VA examinations and opinions in this case are more than adequate, as they reflect a review of the Veteran's claims file, consider all of the pertinent evidence of record, and provide rationales for the opinions offered. They consider all of the pertinent evidence of record, including the statements of the Veteran. Accordingly, the Board finds that VA's duty to assist has been met. 38 C.F.R. § 3.159(c) (4); Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008). Legal Analysis With respect to the Veteran's claims, 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 this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Court of Appeals for the Federal Circuit (Federal Circuit) has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. In general, a veteran is entitled to service connection for a disability resulting from a disease or injury incurred or aggravated during active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection also is permissible for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, such as cardio-vascular disease (including hypertension), may be presumed to have been incurred during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Secondary service connection may be granted for a disability which is proximately due to, the result of, or aggravated by an established service-connected disorder. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Secondary service connection includes instances in which an established service-connected disorder results in additional disability of another condition by means of aggravation. Allen, supra. During the course of this appeal, VA amended 38 C.F.R. § 3.310 effective October 10, 2006). See 71 Fed. Reg. 52,744 -47 (Sept. 7, 2006). To whatever extent the revised regulation may be more restrictive than the previous one, the Board will afford the Veteran review under both the old and new versions. See VAOPGCPREC 7-2003 (Nov. 19, 2003). In each case where a veteran is seeking service connection for any disability, due consideration shall be given to the places, types, and circumstances of such veteran's service as shown by such veteran's service record, the official history of each organization in which such veteran served, such veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 38 U.S.C.A. § 5107(b). CAD and Hypertension The Veteran contends that his CAD is related to active duty or his hypertension. He contends that his CAD began during active duty in 1975. He has consistently stated that he was treated for hypertension or elevated blood pressure in the years immediately after service. The Veteran's service treatment records are negative for any findings that were attributed to heart disease. A December 1972 induction examination indicates that the Veteran's blood pressure was 116/78. In January 1975, the Veteran complained of chest pain after lifting heavy ammunition. He was treated for a muscle strain. In February 1975, he again complained of chest pain. A chest X-ray and a physical examination were both normal. The diagnosis was "costal chondritis." He was placed on restrictive duty for two weeks. There were no further complaints of chest pain during service. A May 1976 treatment note indicates that the Veteran's blood pressure was 128/78. A February 1977 separation examination was normal. The systolic blood pressure reading was 110; the diastolic reading is illegible. A post-service 1977 private medical record indicates that the Veteran's blood pressure was 140/90. The cardiologist diagnosed mild hypertension. There is no indication that the doctor prescribed any blood pressure medication. The Veteran underwent a VA examination in January 1978 for left shoulder and chest pain. The examination yielded normal cardiovascular findings. The Veteran was diagnosed with hypercholesterolemia in November 1979. His blood pressure was 122/90. He complained of chest pain of two weeks' duration in November 1980. His blood pressure was 130/80. Diagnoses at the time included status post upper respiratory infection and costochondritis. The Veteran complained of chest (and back) pain again in September 1985. The pain was of only one day's duration. His blood pressure was 123/73. The clinician noted bibasilar rales somewhat greater on the left than the right and diagnosed pleuritic left chest pain. The Veteran complained of chest pain again in January 1988. This time he noted that the chest pain was of three days' duration. No diagnosis was made. His blood pressure was 130/82. A March 1997 ECG was normal. In January 1998, the Veteran was diagnosed with CAD. The doctor noted that the Veteran's risk factors for CAD included his age, male sex, and hyperlipidemia. He stated that the Veteran had not been treated for hypertension or diabetes, and that there was no family history of heart disease. The Veteran subsequently underwent a selective coronary angiography. August 1999 and March 2000 treatment notes indicate that the Veteran had no cardiovascular complaints and that no further cardiovascular follow up was needed. The claims file contains voluminous VA and private medical records dated during the appeal period through 2009 and 2011, respectively. These records reflect ongoing treatment for the Veteran's claimed heart conditions but do not provide any medical evidence or opinions that link either disability to the Veteran's active duty, show that either disability was manifest during the initial one-year period after active duty, or show that the Veteran's hypertension caused or aggravated his CAD. November 2003 correspondence from W.T., M.D., documents the Veteran's cardiac history, which included angina during a December 1997 treadmill test and an abnormal February 1998 EKG. He noted that the Veteran had not complained of retrosternal exertional chest pain since the January 1998 selective coronary angiography. The doctor provided the following opinion: Due to [the Veteran's] long history of recurrent retrosternal pain with an exertional component and his personal history of hyperlipidemia, and a family history of cardiovascular disease, it is conceivable that his CAD may have been present in January of 1975. Diagnostic studies were not done in January of 1975. It is impossible to rule out CAD at that time. The Veteran underwent a VA heart examination in April 2004. The Veteran complained of occasional chest and neck discomfort with exercise. A cardiac examination was normal. His blood pressure was 130/90 and 140/90. The examiner indicated that he had thoroughly reviewed the claims file. He noted that CAD was not diagnosed until 1998, and that the service treatment records did not indicate any complaints of exertional chest pain that would be suggestive of angina pectoris secondary to CAD. The examiner also noted an abnormal electrocardiogram in 1988 by Dr. W.T. He acknowledged the Veteran's report of chest pain since service. However, the examiner observed that the Veteran would have been 28 years old at the time, and determined that it "would be unusual for him to have had CAD manifesting its symptoms that only slowly progressed over the next 23 years." The examiner stated that "[t]here is a question of a history of hypertension and he is not certain of this although he does apparently take Lopressor in addition to Lovastatin for his hyperlipidemia." The diagnoses were CAD, status post PTCA and stenting of the left anterior descending and right coronary arteries in January 1998. The examiner noted the Veteran's hyperlipidemia, light cigarette smoking, and "possibly mild hypertension" as risk factors for CAD. Although he stated that "it is more likely than not that the CAD existed while [the Veteran] was in the service," the examiner also noted that the medical records did not support such a finding. He determined that the abnormal electrocardiogram in 1988 was consistent with the Veteran's reports of chest pain and that "if in fact he was having exertional chest pain as he states then that would be compatible with CAD existing as far back as the military service." However, the examiner opined that he could not resolve this issue since the claims file did not contain the 1988 electrocardiogram or evidence of the preexistence of exertional chest pain. He agreed with Dr. W.T. that it was impossible to rule out CAD during service, and stated that "it is conceivable that his CAD may have been present as far back as 1975." A June 2004 medical record from Dr. W.T. contains the following statement: He is concerned that he will not have a positive outcome to his VA claim for the chest pain occurring in 1975 having a connection to heart disease. Diagnosed with CAD in 1998. I again explained to him that the lack of documentation in 1975 does not allow stating that the 1975 chest pain (documented as costochondritis) was indeed pain caused by his heart . . . I cannot change the possibly related to CAD (1975 chest pain at age 26) to clearly related to heart disease. The Board finds that the opinions from Dr. W.T. and the April 2004 VA examiner ultimately do not show that it is at least as likely as not that the Veteran had CAD during active duty, and thus do not support the Veteran's claim. These opinions are qualified and ambiguous. At best, Dr. W.T. and the April 2006 VA examiner state that it was impossible to rule out CAD during service, and the Veteran's CAD could have been present during active duty. However, the award of VA benefits may not be predicated on a resort to speculation or remote possibility. 38 C.F.R. § 3.102; see Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) (a letter from a physician indicating that veteran's death "may or may not" have been averted if medical personnel could have effectively intubated the veteran held to be speculative); Obert v. Brown, 5 Vet. App. 30, 33 (1993) (physician's statement that the veteran may have been having some symptoms of multiple sclerosis for many years prior to the date of diagnosis deemed speculative). During the July 2004 RO conference, the Veteran stated that he got out of the military because whenever he complained of chest pain he was accused of malingering and given aspirin. He further stated that he continued to have chest pain post-service until 1998. An August 2005 private medical abstract summarizes the Veteran's medical history and provides the following diagnoses: (1) hypertension since 1978, uncontrolled; (2) dyslipidemia, uncontrolled; (3) left ventricular hypertrophy secondary to chronic hypertension; and (4) atherosclerosis secondary to chronic dyslipidemia. It is not clear whether the history was obtained from the Veteran or his medical records. A May 2006 ECG revealed non-specific ST-T wave changes. The Veteran underwent a VA heart examination in September 2006. The examiner indicted that she thoroughly reviewed the claims file, to include the February 1988 ECG. The Veteran reported that he began having chest pain in 1975. The pain radiated to the upper chest and was caused by lifting heavy ammunition or running for three miles. The examiner noted that the Veteran was treated and diagnosed with costochondritis. The Veteran indicated that he worked on base as a civilian employee from 1977 to 2003, and continued to have recurrent chest pain upon exertion, which he rated as 5/10. Serial ECG's were negative. The Veteran reported that since May 1999 he had noted a daily reoccurrence of chest pain caused by eating, prolonged walking, or deep breathing. He rated the pain as 6/10. He complained of fatigue, angina, and dizziness. Aside from an inadequate stress test, all cardiac tests were normal. The examiner diagnosed CAD status post PTCA with stenting and hypertension, stage 2, uncontrolled. She determined that "[i]t is less likely as not that the CAD began during service nor within one year of service." She noted that there was no objective evidence or risk factor to support the presence of CAD during service, and that no investigation had been done to support the impression of angina pectoris in 1977. She further noted that the Veteran began showing risk factors of CAD when he was 45 years old, to include his age; hyperlipidemia (1992); obesity (1995); and high blood sugar (1995). She noted that he "was suspect to have diabetes in 1993." It was not until 1997 that CAD was documented by a positive stress test. Based on these findings, the examiner made the following statement: It has been established that there is enhanced atherogenesis in diabetic patients due to a cluster of other risk factors including dyslipidemia. However, hyperglycemia itself is now recognized as a leading cause of CAD. This ultimately results in microvascular complications including nephropathy and retinopathy and macrovascular complications such as CAD. The Board finds that thus medical opinion constitutes highly probative evidence against entitlement to service connection for CAD on a direct or presumptive basis. This opinion is based on the Veteran's past medical history and current physical findings, to which the examination refers in detail. This fact is particularly important, in the Board's judgment, as the references makes for a more convincing rationale. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). In a June 2008 letter, N.P., M.D, stated that he treated the Veteran in June and July 1977 for hypertension and chest pain, and prescribed medication. An attached certificate from the Republic of the Philippines Bureau of Fire Protection relates that the all available records from that medical clinic were destroyed by fire in December 1984. In a November 2011 VA expert medical opinion, a VA physician reviewed the pertinent medical evidence in detail. This included quoting actual medical records and opinions. The examiner pointed out that there were generally no symptoms of CAD until there was a clear-cut flow-limiting lesion or several of the same present in the epicardial arteries. In the Veteran's case, the examiner stated that it was "highly unlikely" that CAD with flow-limiting lesions sufficient to case symptoms was present in January 1975 and did not truly manifest itself until January 1998. He stated that flow-limiting lesions caused a progression of symptoms, and in the Veteran's case there was no evidence of any flow-limiting lesion causing clinical symptoms until 1998. As a result, the examiner stated that he was in substantial disagreement with Dr. W.T.'s commentary. He stated that he did not agree with Dr. W.T. that flow-limiting lesions were as likely as not present during the Veteran's active duty or the first year after active duty. He stated that Dr. T's commentary "simply is unrealistic." The examiner stated that he was "in full agreement with" with the medical opinion set forth in the September 2006 VA examination report. He stated that the September 2006 negative opinion was supported by the Veteran's blood pressure readings during active duty, within one year of active duty, and until 1998; the September 2006 findings of normal wall ventricle with good wall motion and contractility, good systolic function and a ventricular ejection fraction of 78 percent; and the normal September 2006 echocardiogram. He stated that it was extremely unlikely that if the Veteran had any form of hypertension from 1977 or immediately thereafter up until 1998 or 2006 he would have had a normal heart size as shown by the 2006 echocardiogram. The examiner stated that he agreed that the Veteran's various episodes of chest pain were costochondritis and chest wall pain. He pointed out that if there was a typical angina pectoralis with or without typical electrocardiographic changes, he would have most definitely expected a continuation of such symptoms, ultimately with objective manifestations of myocardial ischemia, that were not present until 1998. There was a paucity of convincing evidence from 1977 to 1998 that any form of diagnosable clinical event secondary to CAD was present. The examiner specified that in his opinion there was no evidence that there was a causal or etiological relationship between any aspect of the Veteran's 1972 to 1977 active duty and the subsequent events of January 1998. He stated that in his opinion, there was no evidence whatsoever to relate the Veteran's symptoms during service, as documented in his service treatment records, to January 1998. Based on the Veteran's medical records, it appeared that at some time in 2004 the Veteran had diastolic or systolic pressures which met the current standard criteria for diagnosis of hypertension. The examiner stated that in his opinion the Veteran's CAD became clinically manifest in January 1998, and referred to his earlier discussion of flow-limiting lesions. As to whether the Veteran's cardiovascular pathology that led to his January 1998 surgery related to symptoms and signs that may have occurred within one year of his separation from active duty in March 1997, the examiner provided "a very strong no." He explained that Dr. N.P.'s statement lacked any objective evidence either in the form of documentation in records or consequences of any disease process which he presumed to diagnosis. Dr. N.P.'s commentary "simply is inconsistent with present medical knowledge and standard medical procedures." The examiner reiterated that he would rely very strongly on the date of verifiable symptoms of either hypertension or CAD as times to date the onset of disease for compensation purposes. Therefore, he would date the onset of CAD to the event of January 1998 and hypertension to the onset of sustained elevations of blood pressure in 2004. In his opinion, the CAD antedated the presence of sustained primary hypertension based on the records at hand. As to whether the Veteran's hypertension resulted in a chronic cardiac condition to include CAD, the examiner stated that the Veteran's hypertension probably occurred after the CAD, not before. The Board finds that the November 2011 VA expert medical opinion constitutes highly probative evidence against service connection for CAD and hypertension on any possible basis. The examiner explained his opinions with specific references to the Veteran's active duty and post-service medical history. The examiner analyzed the specific findings in the medical record in terms of medical principles. This fact is particularly important, in the Board's judgment, as the references make for a more convincing rationale. See Bloom, supra (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). See Prejean, supra (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Elkins, supra (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). Notwithstanding the Veteran's assertions to the contrary, there is no indication of an onset of CAD during service or for many years thereafter. The Veteran's in-service complaints of chest pain were not attributed to heart disease; rather, it was believed to be musculoskeletal in origin (muscle strain or costochondritis), and the separation examination revealed a normal heart and circulatory system. There is no medical evidence of CAD until approximately 20 years after service. The Board acknowledges the assertions by the Veteran in support of his claim. He is competent to testify as to his observable symptoms during and after active duty. The Board finds that his assertions are credible. However, the Veteran's contentions that he incurred CAD or hypertension during or as a result of active duty, or that his hypertension caused or aggravated his CAD, do not constitute medical evidence in support of his claim. Although lay persons are competent to provide opinions on some medical issues, the specific issues in this case (whether the Veteran's CAD and hypertension are related to active duty, and whether his hypertension proximately caused or aggravated his CAD) fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). As a result, the Veteran's assertions cannot constitute competent medical evidence in support of his claim. The Board is aware that lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). Additionally, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Further, lay 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. Jandreau, supra. The Veteran is competent to state that he observed the claimed symptoms during or after service. The Board finds him to be credible in this regard, although it points out that he did deny pertinent symptoms at separation. However, he is not competent to attribute the coincidence of symptoms occurring during or after service as establishing the diagnosis and etiology of his current CAD and hypertension. As such, the Board finds that the Veteran's assertions are outweighed by the VA medical opinions addressed above. As service connection for hypertension is denied, service connection for CAD as secondary to hypertension must be denied. 38 C.F.R. § 3.310; Allen, supra. In sum, the evidence demonstrates that the Veteran is not entitled to service connection for CAD, to include as secondary to hypertension, or service connection for hypertension. As the preponderance of the evidence is against these claims, the benefit of the doubt doctrine is not for application. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). Right Thigh The Veteran contends that he now has a right thigh disability as a result of an injury incurred during active duty. In a June 2008 statement, the Veteran's distant relative stated that he witnessed the Veteran favor his right leg. The Veteran informed him that he had experienced chronic pain on the right distal thigh since dropping a large wrench on his right thigh during active duty. The Veteran's service treatment records establish that he sustained a contusion to the right thigh in March 1975 after a wrench fell on him. He complained of pain, and there was edema and tenderness upon examination. McMurray's and Drawer testing were negative. There was some question of lateral instability. The impression was contusion, right thigh. The Veteran was instructed in quad strengthening exercises and discharged. No further complaints were noted. The Veteran's separation medical history and medical examination were negative for pertinent complaints, symptoms, findings or diagnoses. A May 1996 VA joints examination report indicated no abnormalities. X-rays were normal. The impression was contusion of the right thigh with continuing arthralgia pains. In June 1977, D.R., M.D., noted that the Veteran complained of right distal thigh tenderness at the tissue site of an in-service injury. In May 2006, R.N, M.D., noted that the Veteran complained of moderate to severe pain of the right distal thigh, and had a positive history of an in-service right thigh contusion. The claims file contains voluminous VA and private medical records dated during the appeal period through 2009 and 2011, respectively. These records do not provide any medical evidence that the Veteran has current residuals of an active duty contusion of the right distal thigh. The report of the January 2009 VA examination sets forth the relevant history, the Veteran's subjective complaints, and examination results. The examiner provided the opinion that the Veteran's right thigh pain was not caused by or a result of an injury to the right thigh incurred during military service. As a rationale, the examiner explained that when discharged in 1977, 2 years after the thigh contusion, the Veteran's history and medical examination showed that he had normal lower extremity findings. There was no evidence or medical record of any residual effects of the injury up to one year after discharge from service. Recent X-rays showed normal findings in the hips and femur, right. The examiner noted that contusions/hematomas generally heal completely with time. On X-ray, no calcifications in the soft tissue of the quadriceps muscle were seen, and hence the condition had healed completely. By 1977, the Veteran's medical discharge was documented as normal lower extremities. Thus, the Veteran's right thigh pain at present was not caused by or a result of the injury to the right thigh during military service. The Board finds that the January 2009 VA medical opinion constitutes highly probative evidence against service connection for a right thigh disability. The examiner explained his opinion with specific references to the Veteran's active duty and post-service medical history. The examiner analyzed the specific findings in the medical record in terms of medical principles. This fact is particularly important, in the Board's judgment, as the references make for a more convincing rationale. See Bloom, supra (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). See Prejean, supra (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Elkins, supra (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). The Board acknowledges the assertions by the Veteran and his relative in support of his claim. They are competent to testify as to observable symptoms during and after active duty. The Board finds that their assertions are credible. However, their contentions that the Veteran incurred a right thigh disability during active duty as a result of his contusion do not constitute medical evidence in support of his claim. Although lay persons are competent to provide opinions on some medical issues, the specific issues in this case (whether the Veteran has current residuals of an active duty contusion to the right distal thigh) fall outside the realm of common knowledge of a lay person. See Kahana, supra; Jandreau, supra (lay persons not competent to diagnose cancer). As a result, their assertions cannot constitute competent medical evidence in support of the Veteran's claim. The Board is aware that lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno, supra. Additionally, when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. Further, lay 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. Jandreau, supra. The Veteran and his relative are competent to state that they observed the claimed symptoms during or after service. The Board finds them to be credible in this regard, although it points out that the Veteran did deny pertinent complaints at separation. However, they are not competent to attribute the coincidence of symptoms occurring during or after service as establishing that the Veteran now has a right thigh disability as a result of the active duty contusion. As such, the Board finds that their assertions are outweighed by the VA medical opinion addressed above. In addition, pain alone does not in and of itself constitute a disability for which service connection may be granted. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999). In this case, while the Veteran complains of right distal thigh pain, he has not been diagnosed with any current right thigh disability. The Court has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Brown, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Accordingly, service connection for residuals of a contusion of the right distal thigh is denied. In sum, the evidence demonstrates that the Veteran is not entitled to service connection for residuals of a contusion of the right distal thigh (also claimed as right thigh pain). As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See generally Gilbert, supra; Ortiz, supra. ORDER Service connection for CAD, to include as secondary to hypertension, is denied. Service connection for hypertension is denied. Service connection for residuals of a contusion of the right distal thigh (also claimed as right thigh pain) is denied. REMAND A preliminary review of the record indicates that the Veteran's claim for a rating in excess of 10 percent for bilateral tinea pedis requires additional development. In this case, the most recent VA examination of the Veteran's service-connected tinea pedis was conducted in 2005, nearly 8 years ago. Statutes and regulations require that VA assist a claimant in providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In addition, the Court has held that when a veteran claims that a disability is worse than when originally rated, and the available evidence is too old to adequately evaluate the current state of the condition, VA must provide a new examination. See Olsen v. Principi, 3 Vet. App. 480, 482 (1992), citing Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). Accordingly, the case is REMANDED for the following action: 1. Obtain the names and addresses of all medical care providers who treated the Veteran for tinea pedis since 2005. After securing the necessary release, the RO should obtain these records. 2. After completion of the foregoing, schedule the Veteran for an examination by an appropriate VA examiner to determine the nature and current level of severity of the Veteran's bilateral tinea pedis. The claims file must be made available to the examiner. The examination should comply with AMIE protocols for the appropriate examination. A complete rationale for all opinions expressed must be provided. 3. Then, readjudicate the Veteran's claim. If the benefit sought on appeal remains denied, the Veteran and his representative should be provided an SSOC and afforded an opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs