Citation Nr: 1319168 Decision Date: 06/12/13 Archive Date: 06/21/13 DOCKET NO. 06-03 778 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for tension headaches, to include as secondary to posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for peripheral vascular disease (PVD) with claudication, to include as secondary to cold injuries of the bilateral feet and hands and/or PTSD. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD Jebby Rasputnis, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1969 to December 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in May 2005 by the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama. In December 2009, the Board, in pertinent part, denied service connection for tension headaches and PVD; the Board remanded a claim for service connection for posttraumatic stress disorder (PTSD). The Veteran appealed the denials to the U.S. Court of Appeals for Veterans Claims (Court). In March 2011, the Court vacated the decision and remanded the appeal for compliance with the instructions in a Joint Motion for Remand. In September 2011, the Board remanded the appeal, to include the claim for service connection for PTSD, for further development. As the agency of original jurisdiction (AOJ) subsequently granted service connection for PTSD in a November 2012 rating decision, that issue is no longer before the Board for appellate review. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). The Board again remanded the remaining issues for additional development in March 2013. The case now returns for further appellate review. In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's appeal. A review of the virtual file does not reveal any additional evidence pertinent to the present appeal. FINDINGS OF FACT 1. Tension headaches are not shown to be causally or etiologically related to any disease, injury, or incident during service and are not caused or aggravated by a service-connected disability. 2. PVD is not shown to be causally or etiologically related to any disease, injury, or incident during service and was not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. Tension headaches were not incurred in or aggravated by the Veteran's active duty military service and are not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2006), (2012). 2. PVD was not incurred in or aggravated by the Veteran's active duty military service and is not proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2006), (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice 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. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the Court held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, November 2004 and January 2005 letters, sent prior to the initial unfavorable rating decision, advised the Veteran of the evidence and information necessary to substantiate his claims for service connection for tension headaches and PVD, respectively, as well as his and VA's responsibilities in obtaining such evidence and information. Subsequent letters, dated in September 2011 and January 2013, informed the Veteran of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Moreover, the January 2013 letter also advised the Veteran of the evidence and information necessary to substantiate his claims for service connection on a secondary basis. Although the September 2011 and January 2013 letters were issued after the initial rating decision, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that VA can cure such a timing problem by readjudicating the Veteran's claim following the issuance of a compliant VCAA notification letter. Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Court clarified that the issuance of a statement of the case could constitute a readjudication. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In the instant case, after the September 2011 and January 2013 letters were issued, the Veteran's claims were readjudicated in supplemental statements of the case issued in January and April 2013. Therefore, any defect with respect to the timing of the VCAA notice has been cured. Relevant to the duty to assist, the Veteran's service treatment and personnel records, as well as private treatment records, have been obtained and considered. Further, the Veteran has not identified any additional, outstanding records that have not been requested or obtained. Moreover, in April 2013, he submitted an 'Expedited Processing' form containing an attestation that he did not have any further evidence to submit. Therefore, the Board finds that VA has satisfied its duty to assist in this regard. Additionally, the Veteran was afforded VA examinations in March 2005 and October 2011. The March 2005 was a general medical examination that did not result in any etiological opinions, but the October 2011 examiner offered etiological opinions in regard to both headaches and PVD. Addendum opinions as to headaches and PVD were issued in April 2013. The Board finds that the October 2011 VA examinations and etiological opinions, with the April 2013 addendum opinions, are adequate to decide the issues. The examinations are predicated on interview with the Veteran as well as physical examination and, further, the examiner noted review of the record, to include the Veteran's service treatment records. The ultimate opinions proffered considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided complete rationales, relying on, and citing to, the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the issues decided herein has been met. The Board remanded this case in September 2011 and March 2013 in order for the AOJ to provide the Veteran with additional VCAA notice (to include notice as to secondary service connection), further develop the claims by assisting the Veteran in gathering additional evidence and affording him examinations, and readjudicate the claims. The record reflects that the AOJ provided the Veteran with additional VCAA notice letters in September 2011 and January 2013 (addressing secondary service connection); in these letters, the AOJ requested that the Veteran provide VA with authorization to obtain any outstanding private medical evidence on his behalf, but the Veteran has not indicated that any private evidence remains outstanding. Examinations were conducted in October 2011 with an addendum opinion issued in April 2013. The AOJ also subsequently issued an April 2013 supplemental statement of the case reflecting readjudication of the claims. Therefore, the Board finds that the prior remand directives have been substantially complied with such that no further action is necessary in this regard. See D'Aries, supra. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Analysis The Veteran contends that he experiences tension headaches either as the direct result of service or secondary to, to include aggravated by, PTSD. He also contends to experience PVD as the result of service, as the result of service-connected cold injury residuals, or as aggravated by PTSD. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in- service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. In some cases, service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Inasmuch as the Veteran is not claiming entitlement to service connection for a disease recognized as chronic under 38 C.F.R. § 3.309(a), the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology are inapplicable. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). The Board notes that the provisions of 38 C.F.R. § 3.310 were amended during the pendency of the Veteran's appeal, effective October 10, 2006; however, the new provisions state that service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). Although the stated intent of the change was merely to implement the requirements of Allen, supra, the Board finds that the new provisions amount to a substantive change to the manner in which 38 C.F.R. § 3.310 has been applied by VA in Allen-type cases since 1995. Consequently, the Board will apply the older version of 38 C.F.R. § 3.310, which is more favorable to the Veteran as it does not require the establishment of a baseline level of disability before an award of service connection may granted. See generally, Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-2003. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. Tension Headaches The Veteran's service treatment records reflect that he was evaluated as normal at both the time of his enlistment and the time of his separation from service. He specifically denied ever experiencing any frequent or severe headaches on a self-report of medical history completed in February 1969 (pre-induction). The subsequent service records are silent for complaints, diagnoses, or treatment of headaches. At the time of his November 1970 separation examination, he stated on the examination report that he was in "good health." The first post-service indication of headaches is a private medical record showing treatment in September 1973 for a headache and sore throat. At that time, the Veteran was diagnosed with pharyngitis. In November 1988, the Veteran was seen for a four day occipital headache. A private physician checked his blood pressure and diagnosed a muscle tension headache. In March 1992, the Veteran was seen for right-sided head and neck pains as well as sinus drainage and cough. The physician noted that he had "probably muscle tension headaches, sinusitis, and bronchitis." He was seen again in April 1992 and reported experiencing "dull headaches" for approximately the last month. An August 1997 private medical record shows that the Veteran reported for treatment of a "severe headache" located on the top of his head that he had experienced "all weekend." He was diagnosed with uncontrolled hypertension. After filing his claim for service-connected benefits, the Veteran submitted an authorization for the release of treatment records from his private physician. He stated on the authorization that he "went to the doctor about headaches, then they discovered [he] had high blood [pressure]." In November 2004, he wrote to VA and stated that he "still ha[s] headaches." The Veteran was afforded a general VA examination in March 2005. At that time, he indicated that he began experiencing headaches in 1970. He reported medical evaluation at that time, but that the physicians had no specific findings. He also reported that he had continued to experience headaches on a weekly basis since that time. At the time of the examination, the Veteran stated that he had headaches on average twice a week, lasting for about one day. Based on the Veteran's description of the headaches, and that they occurred without vomiting, double vision, or increased sensitivity to light, the examiner diagnosed tension headaches. The examiner did not discuss the etiology of the headaches. In October 2011, the Veteran was afforded a VA headaches examination. The examiner summarized the Veteran's treatment history and observed that he reported experiencing headaches, approximately three or four a week, since the 1970s. After reviewing the claims file and interviewing and examining the Veteran, the examiner diagnosed tension headaches. The examiner noted that there was no evidence that a headache disability began in the service and opined that the disability did not start until approximately the 1990s. The examiner also observed that the Veteran had experienced multiple motor vehicle accidents and stated that such accidents can lead to headache residuals when there are concussions. After the Veteran, through his authorized representative, contended that he experienced headaches as secondary to PTSD, the 2011 examiner provided an addendum opinion in April 2013. The examiner explained that "there is not a medically accepted cause and effect pathophysiologic link between PTSD and tension headaches." The examiner based that explanation on a review of cited medical literature as well as his training and experience. He further explained that, based on review of the record, the Veteran's PTSD pre-existed, and was unrelated to, his tension headache disability and, as a result, did not aggravate it beyond a natural progression. The examiner again noted that the headaches were likely attributable to the motor vehicle accidents experienced by the Veteran. The Board notes that the Veteran contends on his own behalf and through his authorized representative that he has a tension headache disability that was incurred in, and has existed since, service. In the alternative, he contends that his service-connected PTSD caused or aggravated his tension headache disorder. A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom., Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998). However, 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, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it pertains to the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). In the instant case, the Board finds that the Veteran, as a lay person, is competent to report experiencing headaches. However, the Board also has a duty to assess the credibility of the evidence. Smith v. Derwinski, 1 Vet. App. 235, 237-38 (1991); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence of the in-service event (see Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006)), but, the Board may discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See Caluza v. Brown, 7 Vet. App. 498 (1995). Here, the Veteran's service treatment and examination records do not support his contentions that he was seen while on active duty for treatment of tension headaches. Further, the private medical evidence of record does not reflect diagnosis of tension headache until November 1988. Subsequent private medical evidence shows that the Veteran was seen frequently, but did not report headaches on more than isolated occasions. Although a Veteran is generally considered competent to report his or her symptoms (Layno v. Brown, 6 Vet. App. 465, 469 (1994)), the Board finds the Veteran's contentions not credible due to inconsistency and implausibility. Specifically, his reports of when he received treatment and how frequently he experienced headaches is inconsistent with the medical evidence of record and the Board finds it implausible that he would experience headaches as consistently as he has contended, but would only inform his physicians of them on the isolated occasions documented above. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment); See Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). Moreover, contemporaneous evidence has greater probative value than subsequently reported history. See Curry v. Brown, 7 Vet. App. 59, 68 (1994). For these reasons, and because headaches are not recognized as chronic under 38 C.F.R. § 3.309(a), the Veteran cannot support his claim on the basis of his own assertions of continuity of symptomatology, alone. See Walker, 708 F.3d 1331. Although the Veteran is competent to report his symptoms, he is not competent o provide an opinion as to the etiology of any headaches. In this regard, the diagnosis of headaches involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Moreover, the diagnosis of a particular type of headache requires clinical examination and interpretation of examination findings. As such, the question of headache etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is non-probative evidence. See Jandreau, supra; see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). The record reflects only one competent medical opinion as to the etiology of the Veteran's tension headaches - the opinion of the October 2011/April 2013 VA examiner. In determining the probative value to be assigned to this medical opinion, the Board has considered whether the examiner was fully informed of the pertinent medical history of the case, whether or not the opinion was fully articulated and whether the opinion is supported by reasoned analysis. Nieves-Rodriguez v. Peake, 22 Vet. App. 295. Here, the VA examiner reviewed the claims file and summarized his medical history as well as provided a fully articulated medical opinion, as supplemented by the April 2013 addendum. The Board notes that the 2011 opinion indicates that tension headache can result from concussions, but review of the claims file does not show that the Veteran experienced concussions as part of any of the motor vehicle accidents documented in the record. However, the examiner's opinions are still fully articulated and provide reasoned analyses as to why the Veteran's headache disorder is not related to any incident of his active duty service: lack of medical evidence of a tension headache disability until approximately 1990 as well as lack of clinical relationship between tension headaches and the Veteran's service-connected PTSD. For these reasons, the Board finds the opinions (issued in 2011 and 2013) of the VA examiner constitute competent and probative evidence of the lack of an etiological relationship between tension headaches and any incident of the Veteran's service, or his service-connected PTSD. Further, to the extent that the private medical evidence of record may be construed as suggesting that the Veteran's headaches result from hypertension, the Board notes that it denied service connection for hypertension in December 2009. As such, the Veteran lacks legal grounds to establish entitlement to service connection for headaches as secondary to hypertension. See Sabonis v. Brown, 6 Vet. App. 426 (1994). The Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for tension headaches. As such, the benefit-of-the-doubt doctrine is not applicable to this issue and the claim must be denied. 38 U.S.C.A. § 5107. B. Peripheral Vascular Disease The Veteran's service treatment records reflect that he was evaluated as normal at both the time of his enlistment and the time of his separation from service. The records are silent for complaints, diagnoses, or treatment of any peripheral vascular disorders. At the time of his separation examination, he stated on his November 1970 separation examination report that he was in "good health." After service, in November 1998, the Veteran saw his private doctor and reported occasional leg "cramping" while walking; his peripheral pulses were noted to be normal and the physician listed no diagnosis other than hypertension. In June 1999, the Veteran informed his private physician that he experienced severe leg pain after walking only a short distance. The physician noted his diagnosed hypertension as well as claudication and ordered a Doppler study of the lower extremities. The results showed decreased blood flow, so he was referred to a vascular surgeon and underwent an angioplasty. His private physician noted in July 1999 that the Veteran reported his leg discomfort dissipated after the angioplasty. However, an April 2000 private medical record shows that the Veteran had begun to experience nocturnal leg cramps. In July 2000, the Veteran informed his private physician that he had begun to re-experience day time leg cramping. The physician noted that he could not palpate any distal pulses in the lower extremities and diagnosed PVD. Subsequent private medical records show ongoing treatment for the Veteran's PVD with claudication. A February 2004 lower extremity Doppler study revealed heavy/extensive calcification in the arterial system of the bilateral lower extremities. In March 2004, one of the Veteran's private physicians noted that his claudication of the lower extremities was "secondary to superficial femoral artery occlusion, bilaterally." The Veteran underwent femoropopliteal bypass grafting later that month in order to treat his claudication. The surgery revealed that the occlusion was caused by moderate atherosclerotic disease of the common femoral artery and the popliteal artery. The Veteran's private physician authored multiple letters informing other clinicians, who were involved with the Veteran's care, of the results of the surgery. At the March 2005 general VA examination, the Veteran indicated that he began noticing aching in both lower extremities in approximately 1985 and the condition became worse with time. The examiner observed that he had undergone arteriograms in 1999 which showed significant peripheral vascular disease and had been treated by femoropopliteal bypass grafting. The examiner diagnosed PVD. The Veteran was afforded a VA artery and vein examination in October 2011. The examiner interviewed and examined the Veteran and noted clinical findings of arteriosclerosis obliterans in each of the lower extremities. The examiner diagnosed him with PVD, but explained that there was no clinical evidence of PVD at the time the Veteran was in service as his peripheral pulses were noted to be normal at the time of in-service examination. Although observing that the Veteran attributed his PVD to his cold injury residuals, the examiner explained that cold injuries are not a risk factor for the PVD experienced by the Veteran because the PVD-affected blood vessels were at his thigh level, away from where cold injuries were incurred. The examiner identified the Veteran's hypertension, coronary artery disease, and smoking habits as risk factors for PVD. The claims file was returned to the VA examiner in April 2013 to provide a clarifying opinion. Specifically, the examiner opined that "PVD started well after the [Veteran's] service and the onset and pattern does not correlate with the residuals from cold injuries." The examiner explained that neither the service-connected cold injuries, nor the Veteran's service-connected PTSD, could have aggravated the PVD beyond a natural progression because they were incurred prior to any PVD; further, the cold injury residuals were located in a different part of the lower extremities and were a small vessel injury whereas the Veteran's PVD was a large vessel disease. The record shows that the Veteran has been diagnosed with PVD. However, the most competent and probative evidence of record reflects that he does not experience PVD as the direct result of service, as the result of a service-connected disability, or as aggravated by any service-connected disability. Specifically, the Veteran's private physician opined in multiple letters written in 2004 that the Veteran experienced PVD secondary to occlusion of the femoral artery; Doppler studies revealed that occlusion was the result of atherosclerotic disease of the common femoral artery and the popliteal artery. Further, the October 2011/April 2013 VA examiner provided a reasoned opinion as to why PVD did not result from, or develop during, the Veteran's active duty service, did not exist secondary to cold injury residuals, and was not aggravated by either PTSD or cold injury residuals. The Board finds these opinions competent and probative. See Nieves-Rodriguez, 22 Vet. App. 295; Stefl, 21 Vet. App. at 124. The Board notes that the Veteran himself has stated that his PVD is related to service or a service-connected disability. In this regard, the Board notes that the matter of diagnosis and etiology of the complex disability under consideration is one within the province of trained professionals as it is an internal process (venous disease) not capable of lay observation. See Woehlaert, supra. As the Veteran is not shown to have any medical training or expertise, he is not competent to render a probative (i.e., persuasive) opinion the medical matter upon which this claim turns. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998); see also Routen v. Brown, 10 Vet. App. 183, 186 (1997). Hence, his lay assertions regarding etiology have no probative value in this appeal. The Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for PVD. As such, the benefit-of-the-doubt doctrine is not applicable and the claim must be denied. 38 U.S.C.A. § 5107. Although the Board has herein decided that service connection for PVD cannot be granted based on the current record, it observes that the Veteran's private physician, as well as the October 2011/April 2013 VA examiner indicated that PVD may result from coronary artery disease. The Veteran filed a claim for service connection for coronary artery disease that was denied by the Board in December 2009. However, since that time, VA has passed regulation conceding exposure to herbicides on a presumptive basis for Veterans who served between April 1, 1968 and August 31, 1971, in a unit that either VA or the Department of Defense (DoD) recognizes as having operated in or near the Korean demilitarized zone (DMZ). As the Veteran has contended that he served in the DMZ, and as pertinent law recognizes coronary artery disease as a disease associated with exposure to herbicides (such that service connection is warranted on a presumptive basis for qualifying Veterans, 38 C.F.R. § 3.309(e)), the Veteran may wish to file new claims for service connection for coronary artery disease and any associated disabilities. ORDER Service connection for tension headaches is denied. Service connection for peripheral vascular disease is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs