Citation Nr: 1319293 Decision Date: 06/13/13 Archive Date: 06/21/13 DOCKET NO. 09-40 125 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Hartford, Connecticut THE ISSUE Entitlement to service connection for a right ankle disorder. REPRESENTATION Appellant represented by: Connecticut Department of Veterans Affairs ATTORNEY FOR THE BOARD K. Marenna, Associate Counsel INTRODUCTION The appellant had active service from February 1959 to March 1962. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Hartford, Connecticut. The case was previously before the Board in April 2011. In the April 2011 decision, the Board reopened the appellant's claim for service connection for a right ankle disorder and remanded the reopened claim for additional development. In June 2011, the Board requested an opinion from a Veterans Health Administration (VHA) medical expert. An opinion was obtained in September 2012 and incorporated into the record. The appellant was provided with a copy of the VHA opinion. In November 2012, the Board remanded the claim for additional development. For the reasons discussed below, the Board finds that there has been substantial compliance with the mandates of the November 2012 remand and will proceed to adjudicate the appeal. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In March 2013, the Board received a statement from the appellant. The Board notes that VA regulations require that pertinent evidence submitted by the appellant must be referred to the agency of original jurisdiction for review and preparation of a supplemental statement of the case (SSOC) unless this procedural right is waived in writing by the appellant or representative. 38 C.F.R. §§ 19.37, 20.1304 (2012). Although the appellant did not waive RO consideration of the new evidence, the statement is duplicative of evidence previously of record. Thus, the Board finds no prejudice to the appellant in proceeding to adjudicate this appeal. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). FINDING OF FACT There has been no demonstration by competent medical, or competent and credible lay, evidence of record that the appellant has a right ankle disorder that is related to service. CONCLUSION OF LAW A right ankle disorder was not incurred in, or aggravated by, active service. 38 U.S.C.A. §§ 1110, 1131, 1154, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has thoroughly reviewed all the evidence in the appellant's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, each piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Notice and Assistance VA has met all statutory and regulatory notice and duty to assist provisions as to the appellant's claim for service connection for a right ankle disorder. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2012). When VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012). The United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002); Pelegrini v. Principi, 18 Vet. App. 112 (2004); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Court observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 490 (2006); see also 38 U.S.C. § 5103(a). Compliance with the first Quartuccio element requires notice of these five elements. See id. Prior to initial adjudication of the appellant's claim, a letter dated in November 2008 fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, 16 Vet. App. at 187; Dingess/Hartman, 19 Vet. App. at 490. VA's duty to assist has been satisfied. The appellant's service treatment records and VA medical records are in the file. As requested by the Board, an attempt was made to obtain any outstanding clinical records from the medical facility at Fort Dix New Jersey from February 1959 to April 1959 and from the medical facility at Fort Devens, Massachusetts, for the period from April 1, 1959, to May 1959. However, a negative response was received. In a March 2012 memorandum, the AMC described the steps taken to obtain the records. The Board finds that there was substantial compliance with the mandates of the April 2011 remand and that VA satisfied its duty to assist. In the November 2012 remand, the Board noted that there may have been an X-ray report which had not been associated with the claims file. The Board requested VA to obtain copies of any X-rays and/or X-ray reports from the February 2012 examination, if any. A November 2012 report of contact reflects that a message was left requesting any X-ray reports. The appellant was examined in November 2012 and X-rays were obtained at that time. As new X-rays were obtained and it was unclear whether the X-rays referenced in the remand existed, the Board finds that there has been substantial compliance with the mandates of the remand. Private medical records identified by the appellant have been obtained, to the extent possible. The appellant has at no time referenced outstanding records that he wanted VA to obtain or that he felt were relevant to the claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). If VA provides a claimant with an examination in accordance with the duty to assist, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The appellant was afforded February 2012 and November 2012 VA examinations as well as a July 2012 VHA opinion. As discussed below the Board finds that the February 2012 VA examination was inadequate. However, the Board finds that the November 2012 VA examination and July 2012 VHA opinion were adequate. The opinions were rendered by a medical professional. The November 2012 VA examination included a thorough examination and interview of the appellant. The examiners obtained an accurate history and listened to the appellant's assertions. The claims file was reviewed. The examiners laid factual foundations for the conclusions that were reached. Therefore, the Board finds that the November 2012 VA examination and July 2012 VHA opinion are adequate. See Nieves-Rodriguez, 22 Vet. App. at 304. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). II. Legal Criteria Service connection is warranted if it is shown that a Veteran has a disability resulting from an injury incurred or a disease contracted in active service or for aggravation of a pre-existing injury or disease in active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in- service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Certain chronic disabilities, such as arthritis, if manifest to a degree of 10 percent or more within one year after separation from active duty, may be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. III. Analysis The appellant contends that he is entitled to service connection for a right ankle disorder. For the reasons that follow, the Board finds that service connection is not warranted. The appellant has been diagnosed with several disorders involving his right ankle during the appeal period. Specifically, a February 2012 VA examiner found the appellant had diagnoses of mild osteoarthritis of the right ankle, gout and venous stasis. The November 2012 VA examiner noted that the appellant had synovitis. As the appellant had a right ankle disorder during the period on appeal, the first element of a service connection claim has been met. A January 1959 enlistment examination report indicated the appellant's lower extremities and feet were normal. In a January 1959 report of medical history, the appellant denied having foot trouble or a bone, joint or other deformity. An April 1959 service treatment record reflects that the appellant complained of pain of the right ankle which was a reoccurrence from the removal of cast one week ago. Physical examination was negative except for a slight tender joint. The appellant was instructed to use an ace bandage. A February 1962 examination report reflects that the appellant's lower extremities and feet were normal. In a February 1962 report of medical history, the appellant denied having foot trouble, arthritis or rheumatism, or a bone, joint or other deformity. A March 1962 statement signed by the appellant stated that he certified that there had been no change in his physical condition since his last final-type physical examination in February 1962. A September 1987 private treatment record indicates that the appellant reported falling from a ladder and having pain in his right knee and right ankle. He was able to walk but he had persistent pain. The assessment was a fracture of the fibular head. A September 1987 private X-ray report reflects that a fracture of the fibular head was present. The os calcis was normal. An April 1988 private treatment record indicates that the appellant reported having intermittent gout. On examination, his extremities were without joint deformity. A July 1988 private examination report from Dr. R.C. noted that the appellant had a complaint regarding his right ankle. Dr. R.C. noted that apparently the patient's history dated back to September of 1987. At that time the patient fell of a ladder sustaining a fracture to the fibula. This was treated by immobilization. Since that time the patient had intermittent swellings particularly on stressful activity levels. Dr. R.C. stated that apparently the patient developed swelling of the lateral aspect of the ankle on July 5th which became quite severe. The swelling subsided but he had some discomfort. Dr. R.C. stated that of note is the fact that the patient does have a history of gout responding nicely to anti-inflammatory medication. On examination, X-rays of the ankle revealed evidence of the old fracture which had healed in the anatomic position. There were minimally degenerative changes noted. The assessment was one of intermittent synovitis. An October 1992 letter from D.B.G., M.D. stated that the appellant used an occasional Indocin for degenerative arthritis. A November 1993 VA examination report reflects that the appellant reported that he was knocked out by his opponent in hand-to-hand combat, causing him to fall and fracture his right ankle. He reported that at the Fort Dix Hospital, a short leg cast was applied for two months, followed by light duty profile for an additional two months, and then full duty. The appellant reported that since discharge, after doing any heavy work on his feet, his right ankle would become painfully swollen. He would treat this with rest and anti-inflammatory medications and the problem would resolve in a few days. The last time this occurred was three months ago. His chief complaint was recurrent, painful swelling of the right ankle. On examination, range of motion and strength of the ankle were normal. X-rays of the right ankle revealed no residual evidence of the alleged fracture. There was some slight calcification between the right distal tibia and talus. The impression was status post fracture of right ankle from history, manifest by complaints of recurrent, painful swelling. The VA examiner noted that although the appellant did not show any clear evidence of the alleged fracture, he did have a slight amount of calcification between the tibia and talar bone and did give a good history of recurrent swelling and pain in the ankle. The examiner noted that most of this problem may be due to a sprain of the soft tissue, rather than any fracture. As the November 1993 VA examiner did not provide a clear opinion as to whether the appellant had a right ankle disability that is related to service, the report has limited probative value. A December 1993 letter from Dr. R.C. reflects that the appellant had been under his care in the past for chronic, intermittent synovitis of the right ankle. Dr. R.C. stated that apparently there was a discrepancy in the history recorded in the July 1988 office note and the history the appellant now gave. The appellant stated that he did not fracture his ankle in 1987, but instead had a flare-up in symptomatology and swelling. Dr. R.C. stated that the appellant apparently did fracture his ankle while in the service in 1959. He offered pictures of himself in a long-leg cast which would be consistent with the fracture. Subsequent X-rays taken from the office visit did confirm evidence of an old fracture with degenerative changes. Dr. R.C. stated that "it was my feeling at that time that the patient was suffering from intermittent synovitis secondary to the degenerative changes as a result of the fracture of the fibula. If indeed the fracture did occur in 1959 as opposed to 1988, it is still my contention that it is the fracture that is causing the synovitis, and the patient will have intermittent flare-ups of the synovitis secondary to the arthritis caused by the fracture." As discussed below, the Board finds that the appellant fractured his right ankle in service. However, Dr. R.C. did not provide a rationale for his opinion that the appellant and arthritis and synovitis that was related to the fracture. Thus, the opinion is not probative. A January 1994 letter from Dr. J.L.A. reflects that he did not have any old record pertaining to the appellant's care. Dr. J.L.A. stated that if the facts are that you sustained a fracture in 1959 but did not have a fracture in 1987 and he now had traumatic arthritis, it would seem that your arthritis would be secondary to a fracture in 1959. A September 1996 private treatment record reflects that the appellant complained of pain in his ankle on the right side. This had been associated with swelling. The appellant stated that he no new history of an injury. He reported that he had a long history of joint problems including a fracture of the right ankle while in service. On examination, there was diffuse swelling over the right ankle and tenderness and swelling into the lateral border of the foot. An X-ray of the ankle showed normal general architecture. The impression was a flare-up of gout. A January 1997 private treatment record from J.A.M., M.D., stated that the impression was recalcitrant gouty arthritis of the right foot. He noted that he saw no evidence of any other type of inflammatory arthritis. The appellant submitted general articles on post-traumatic arthritis, including one printed in November 2009. As the articles are not specific to the appellant's claim, they have limited probative value and are less probative than the specific medical opinions of record. In an April 2011 statement, the appellant stated that he has had gout since he was around 49. He stated that he took daily Allopurinol which had kept the gout attacks down. In an April 2011, L.C. stated that he worked with the appellant from 1980 to 1990. He stated that during this time, periodically, the appellant would be using crutches or a cane to increase his mobility. He would complain of pain in his big toes. As a lay person, L.C. is competent to report symptoms capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As L.C.'s statement is consistent with the evidence of record, the Board finds it to be credible and thus probative. In a statement received in September 2011, the appellant stated that he broke his right ankle during hand to hand combat training in March 1959. He got his cast served in the Orderly Room of Company G. Since he was half way through 8 week training, he worked there and was not recycled. The appellant was afforded a VA examination in February 2012. The appellant told the VA examiner that he did not have any significant issues with his right ankle at the time of discharge. He reported that his right ankle started to bother him when he was in his 40s (the 1970s). The VA examiner found that the appellant had mild osteoarthritis of the right ankle. He also noted that the appellant had a right ankle fracture unspecified from 1959. The VA examiner found the claimed condition was less likely than not incurred in or caused by the claimed in-service injury. The VA examiner stated that the appellant was placed in a cast in service in 1959 for a right ankle injury, reported by the appellant to be a fracture. There was notation of discomfort at the time the cast was removed. However, for the remainder of his time in service there were no complaints of any ankle discomfort and none was noted at the time of his discharge. The VA examiner noted that no right ankle pain was noted in the claims file until July 1988 with synovitis diagnosed in the right ankle. The appellant has had intermittent gout, and right ankle pain since, at times together. There was a 26 year gap between the time of discharge and claims file evidence of initial complaints of right ankle pain. Gout predated the ankle complaints by 2 years. The VA examiner stated that it is likely that the appellant's current right ankle complaints are the result of his many years of gout flare, weight gain (about 40 lbs per Veteran today) , 1987 fall from a ladder/right fibular head fracture and his right greater than left venous stasis (unrelated to service or right ankle injury) and unlikely to his distance in-service injury. The VA examiner stated that gout is an endocrine imbalance in the metabolism of uric acid. It cannot be caused by a bone fracture. However, once gout is present, trauma/fracture can precipitate the gout attack. Longstanding gout can result in joint pain and degeneration; the VA examiner stated that as likely as not this has occurred to the Veteran. The Board finds that the February 2012 VA examiner's opinion is inadequate. The VA examiner did not consider the appellant's lay statements that he had experienced right ankle pain since the 1970s. The appellant is competent to report symptoms such as pain and the Board finds the appellant's statements that he has had right ankle pain since the 1970s to be credible, as they are not contradicted by the evidence of record. The VA examiner also opined that the appellant had venous stasis which was unrelated to service or a right ankle injury, but she did not provide a rationale for the opinion. As the rationale for the opinion is inadequate, the Board finds that the February 2012 VA examination report is not probative. In the July 2012 VHA opinion, a VA orthopedic surgeon noted that the photograph of the young appellant in uniform appeared to show a short-leg cast, which would be consistent with the expected treatment in 1959 for a distal fibular fracture, but might also have been used to treat a sprain. The VA physician stated that given the lack of record indicating a surgical procedure and the absence of a surgical scar over the ankle, as reported in the February 2012 examination, the fracture, if present, was most likely minimally displaced, with treatment by casting in position. The VA clinician stated that this assumption would be consistent with Dr. G.'s note from July 1998 which noted that minimally degenerative changes were noted. The VA clinician stated that the absence of substantial degenerative change nearly 30 years after the alleged injury makes it extremely unlikely that any subsequent appearance of degenerative joint disease arthritis is a sequelae of the alleged ankle injury. In July 2012, the Board obtained a VHA opinion. The VA orthopedic surgeon found that there was a greater than 50 percent probability that the appellant sustained a fracture to his right lateral malleolus at some time prior to 1988. The VA clinician found that there was little likelihood the appellant's in-service injury would result in long-term sequelae such as synovitis or degenerative change. The VA clinician stated that the lack of degenerative change reported on ankle films from 1988 and 1996 make it extremely unlikely that a residual from his lateral malleolar fracture contributes to his current ankle complaints. The VA clinician noted that the appellant's long-standing obesity should be considered as a more likely contributor to his ankle complaints than the residual from a minimally displaced, distal fibular fracture in anatomic position. The VA clinician found that it was much less likely than not that the appellant sustained a significant permanent disability or impairment as a result of this fracture. In regard to the appellant's gout, the VA clinician further found that given the number of unrelated risk factors, and the delayed and frequent appearance of gouty flare in multiple locations, it is highly unlikely, probably well below a 10 percent probability that the appellant's gout is related to this lateral malleolar fracture. The VA clinician noted that previously, there was a clinical assumption that gout and the related monosodium urate deposition arthropathy were an occasional sequelae to post-traumatic arthritis. Current clinical thought is that the presence of osteoarthritis predispose to crystalline deposition arthropathy from local monosodium urate crystal buildup in the cartilage and synovium, but the osteoarthritis is not a risk factor for the development of gout per se. The VA clinician cited a medical article to support this statement. The VA clinician also noted that the appellant had a number of factors that put him at much greater risk for the development of gout than the relatively minor residual from the ankle fracture described including his long-standing hypertension and the use of diuretics to treat it. Additionally, obesity is a predisposing factor. The VA clinician also addressed the venous stasis, finding that it is extremely unlikely, probably well below 5 percent, that the mild venous stasis changes seen in the photographs provided by the appellant were related to his right lateral malleolar fracture. The VA clinician noted that trauma rarely results in venous stasis unless there is a substantial, concurrent soft tissue injury that results in disruption of the venous and/or lymphatic system. It may also be as a sequelae to deep vein thrombosis where it is known as post-phlebitic syndrome or post-thrombotic syndrome. In both instances, the signs and symptoms of the venous restriction would be expected to appear within months of the injury. Thus given the relatively recent appearance of the stasis changes, the VA clinician opined that there is little likelihood that the appellant's venous stasis changes are related to an ankle injury occurring in 1959. The VA clinician noted the absence of comparison photographs of the left foot and ankle, raising the question of whether the changes were unilateral. If the changes were bilateral, any consideration that the changes were related to a unilateral ankle injury would be definitely eliminated. The VA clinician found that there was no evidence to support a claim for a right ankle disability arising from a source other than the appellant's well-documented history of gout. Since synovitis is an inflammation of the synovial lining of a joint, and since recurrent gouty episodes are likely to result in the deposition of monosodium urate crystals in the articular cartilage and synovium, the VA clinician stated it is a reasonable assumption that any synovitis the appellant may demonstrate is much more likely to be a residual of his gout, than an injury that occurred over fifty years ago, absent any significant signs of post-traumatic degenerative change in the ankle. The VA clinician found that if synovitis is present, it is more likely than not related to his gouty arthropathy and there is little likelihood, again well below the 50 percent threshold, there is any relationship with the 1959 ankle injury. The Board finds the July 2012 VHA opinion to be adequate and probative. As noted in the November 2012 remand, the VA clinician who wrote the VHA opinion noted that there were no recent weights identified in the records provided, but speculated that the appellant's weight was a risk factor for gout. As discussed below, the November 2012 VA examiner found that the appellant had a BMI indicating obesity, which was consistent with the July 2012 VHA opinion rationale noting the appellant had a history of obesity. The July 2012 VA examiner also noted that there were no recent X-ray reports provided for consideration. However, as discussed below, X-rays were taken at the November 2012 VA examination and the November 2012 VA examiner indicated the results were consistent with the July 2012 VHA opinion. The appellant submitted a September 2012 letter from C.S., M.D. In the letter, Dr. C.S. stated that the appellant sustained an ankle fracture while in the Army in the 1950s. Dr. C.S. stated that: This required a cast. I believe that this injury has contributed to pain that has occurred, since this period of time. He does have some varicosities there which could easily be related to the fracture with the presence of the cast over a period of time. Regarding the patient's weight, the cumulative effect of an ankle injury would limit his activity over a period of decades and contribute to any increase in his weight. This increase in weight would predispose him to gout. Gout certainly could involve the ankle because of this old injury given the fact that the gout often appears to enjoy in the joint under stress. This ankle certainly has led to stress in the joint area over time and caused this area to be susceptible to the effects of gout. Dr. C.S. also noted that he had known the appellant for over 20 years and he found him to be an honest and forthright person. He believed the history of his injury in the service was accurate and truthful. Dr. C.S.'s opinion is equivocal. He stated that the varicosities "could easily" be related to the fracture and gout "certainly could involve the ankle because of this old injury." Consequently, the Board finds that the opinion is not probative. The appellant was afforded another VA examination in November 2012. November 2012 X-rays of the right foot indicated there were scattered degenerative changes and heel spur. There was no radiographic evidence of fractures or dislocations present. The November 2012 VA examiner found that the appellant had a right ankle fracture in service, as likely as not a lateral malleolar fracture (as previously reasoned in the July 2012 medical opinion/private orthopedic MD) non-displaced, and well healed. The VA examiner noted that there was no report of any right ankle symptoms on the separation physical examination or within 1 year of separation. The VA examiner noted that the appellant's complaints today were at the medial malleolus as reported separately on 3 to 4 occasions during the interview. In regard to the appellant's gout, the VA examiner stated that initial onset was in 1987, 25 years following discharge. He noted that it was unlikely related to service given the long time to onset of symptoms and is unlikely related to the appellant's in-service fracture as previously reason in the July 2012 VHA opinion. In regard to synovitis, the November 2012 VA examiner stated that the initial onset was in 1988, following the onset of gout symptoms. The VA examiner noted that synovitis is an inflammatory condition presenting with pain, redness and swelling. There was no notation of these symptoms at the time of discharge or within 1 year of discharge. Initial diagnosis appeared to have been made 26 years following discharge and was more likely the result of his gout. The VA examiner also addressed the appellant's bilateral lower extremities varicose veins/venous stasis with report of onset several years ago, many years following discharge from service. The VA examiner stated that varicosities were bilateral and not only on the right leg, making it unlikely the result of the appellant's in-service right ankle fracture/cast. The examiner noted that it is possible for varicose veins to develop following a severe leg injury. However, the appellant's right ankle fracture was a closed simple fracture and would unlikely result in any venous injury. There was no report or evidence of varicose veins at time of enlistment, at discharge, or within 1 year of separation. The VA examiner further found that mild right ankle osteoarthritis was more likely the result of longstanding obesity, gout and synovitis and less likely to in-service healed right ankle fracture given the long time to onset of documented osteoarthritis, about thirty years following discharge. As requested by the Board, the VA examiner addressed the appellant's weight. The VA examiner noted that the appellant was currently 236 pounds and his BMI was 34, indicating obesity. X-rays following discharge from service showed a healed right ankle fracture. His current symptoms were likely the result of his gout, synovitis and obesity which developed years following his healed in-service right ankle fracture as described above and in the July 2012 VHA opinion. As the VA examiner provided a rationale for the opinions, the Board finds the opinions to be probative. The appellant asserts that he has a right ankle disability due to a right ankle injury that was incurred in service. Although the appellant's service treatment records do not specifically note an ankle fracture, the appellant is competent to report an event or the presence of a disability subject to lay observation. See Jandreau, 492 F.3d at 1377. An April 1959 service treatment record indicates the appellant had right ankle pain and had previously worn a cast. There are no records from prior to April 1959 indicating why the appellant wore a cast, and thus there are no records contradicting his claim that he fractured his right ankle in service. A photo of record appears to indicate the appellant wore a cast in service on his right ankle. A September 1987 X-ray report following the appellant's fall from a ladder indicated that the appellant's heel was negative, but he had a fracture of the fibular head. A July 1988 private treatment record from Dr. R.C. noted that X-rays of the ankle revealed evidence of an old fracture which had healed in the anatomic position. Minimally degenerative changes were noted. The fibular head is located near the knee. Thus, the old healed fracture noted in the July 1988 X-ray was not due to the September 1987 fall. As the appellant indicated that the only other time he hurt his ankle was in 1959, the Board finds that the evidence is consistent with a right ankle fracture in service. Thus, the Board finds the appellant's assertion that he fractured his right ankle in service to be credible. Based on the evidence of record, the Board finds that a preponderance of the evidence is against the appellant's claim. The Board finds that the appellant likely had an in-service right ankle fracture, based on the appellant's competent and credible statements. As discussed above, the Board finds the July 2012 VHA opinion and November 2012 VA examination to be probative. The opinions reflect that it is not at least as likely as not that the appellant has a right ankle disorder, to include arthritis, gout, synovitis, or venous stasis, that is related to service. The July 2012 VA clinician found that it was much less likely than not that the appellant sustained a significant permanent disability or impairment as a result of the in-service fracture. Although in the September 2012 letter, Dr. C.S. indicated that the appellant's right ankle gout may be related to the in-service ankle injury, his statement was equivocal and is thus less probative than the July 2012 VHA opinion and November 2012 VA examination which provided opinions with thorough rationales. Similarly, the December 1993 letter from Dr. R.C. and the January 1994 letter from Dr. J.L.A. indicating that the appellant had right ankle disorders related to the in-service fracture are not probative as the doctors did not provide rationales for the opinions. The Board has considered the April 2011 statement from L.C. indicating that the appellant had pain in his big toes and used crutches from 1980 to 1990. Although the Board finds the statement competent and credible, L.C. reported events that occurred nearly twenty years after the appellant's discharge from service and the statement does not show that the appellant had a right ankle disorder that is related to service. The Board specifically finds that a preponderance of the evidence is against the appellant's claim for service connection for right ankle arthritis. The July 2012 VHA opinion reflects that the absence of substantial degenerative change nearly 30 years after the alleged injury makes it extremely unlikely that any subsequent appearance of degenerative joint disease arthritis is a sequelae of the alleged ankle injury. The November 2012 VA examiner also found that mild right ankle osteoarthritis was more likely the result of longstanding obesity, gout, and synovitis and less likely to in-service healed right ankle fracture given the long time to onset of documented osteoarthritis. As discussed above, the private medical opinions of record are less probative than the July 2012 VHA opinion and November 2012 VA examination report. The Board also specifically finds that a preponderance of the evidence is against the appellant's claim for service connection for gout. The July 2012 VHA opinion reflects that given the number of unrelated risk factors, and the delayed and frequent appearance of gouty flare in multiple locations, it is highly unlikely that the appellant's gout is related to the in-service fracture. Similarly, the November 2012 VA examiner found that the appellant's gout was unlikely related to service given the long time to onset of symptoms and the reasons discussed in the July 2012 VHA opinion. As discussed above, the private medical opinions of record regarding the appellant's gout have no probative value, including the September 2012 letter from Dr. C.S. In regard to the appellant's venous stasis, the Board also finds that a preponderance of the evidence is against service connection for venous stasis. The July 2012 VHA clinician found it was extremely unlikely that the mild venous stasis changes were related to his right lateral malleolar fracture. The November 2012 VA examiner stated that varicosities were bilateral and not only on the right leg making it unlikely the result of the appellant's in-service right ankle fracture/cast. He also noted that the report of onset was several years ago, many years following discharge form service. Finally, the July 2012 VHA opinion and November 2012 VA examination also found that if synovitis is present, it is more likely than not related to the appellant's gout and there is little likelihood of any relationship with the 1959 ankle injury. The November 2012 VA examiner noted that synovitis is an inflammatory condition with pain, redness and swelling and there was no notation of any of these symptoms at the time of discharge form service or within 1 year of service. The December 1993 letter from Dr. R.C. indicating that the appellant had synovitis that was related to an in-service fracture is not probative. The appellant has contended that he has a right ankle disability that is related to service. Although a lay person may be competent to report the etiology of disability, a right ankle disorder is not the type of disorder which is susceptible to lay opinion concerning etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Even if the appellant were competent to provide an opinion as to the etiology of a disorder which is typically confirmed by x-rays and medical examination the Board finds that the probative value of any such opinion is outweighed by that of the physician who provided the July 2012 VHA opinion and November 2012 VA examiner, who have education, training and experience in evaluating the etiology of right ankle disorders. The Board has considered whether service connection is warranted based on continuous symptoms of a right ankle disorder since service. See 38 C.F.R. § 3.309(a). The appellant is competent to report symptoms capable of lay observation, such as pain. However, the evidence does not demonstrate the appellant has had continuous symptoms since service. At the time of his discharge from service, the February 1962 examination report was normal and in the February 1962 report of medical history, he denied having foot trouble, arthritis or rheumatism, or a bone, joint or other deformity. The July 1988 private examination report reflects that the appellant had right ankle complaints with a history dating back to September 1987. In the April 2011 statement, the appellant reported having had gout since he was 49, after service. In a March 2013 statement, the appellant stated that he has had chronic gout since 1988. In the November 1993 VA examination, the appellant reported that since discharge, after doing any heavy work on his feet, his right ankle would become painfully swollen. At the February 2012 VA examination, the appellant reported that his right ankle started to bother him when he was in his 40s (the 1970s), which was after his time in service. The Board finds that the overall evidence of record demonstrates that the appellant did not have continuous symptoms of a right ankle disorder since service. As the appellant's November 1993 statement indicating he had symptoms since service is contradicted by the other evidence of record, the Board finds that it is not credible. As noted above, certain chronic disabilities, such as arthritis, if manifest to a degree of 10 percent or more within one year after separation from active duty, may be presumed to have been incurred in or aggravated by service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The evidence of record does not reflect that the appellant had arthritis in his right ankle to a compensable degrees within one year after separation from service. In sum, the Board finds that a preponderance of the evidence is against the appellant's claim for service connection for a right ankle disorder. Accordingly, the Board finds that the preponderance of the evidence is against the appellant's claim. Consequently, the benefit-of-the-doubt rule is not applicable, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). ORDER Entitlement to service connection for a right ankle disorder is denied. ____________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs