Citation Nr: 1319666 Decision Date: 06/18/13 Archive Date: 06/27/13 DOCKET NO. 08-32 124 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Portland, Oregon THE ISSUES 1. Entitlement to service connection for a low back disability, to include as secondary to bilateral pes planus (flat feet) and/or bilateral plantar fibromatosis. 2. Entitlement to service connection for a bilateral knee disability, to include as secondary to bilateral pes planus and/or bilateral plantar fibromatosis. 3. Entitlement to compensation benefits, pursuant to the provisions of 38 U.S.C.A. § 1151, for additional disability resulting from March 2006 surgery and follow-up care for Dupuytren's contracture of the right hand and ring finger. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Andrew Ahlberg, Counsel INTRODUCTION The Veteran served on active duty from August 1969 to May 1971. This appeal to the Board of Veterans' Appeals (Board) arose from a May 2007 rating decision in which the RO, inter alia, denied service connection for a low back disability and a bilateral knee disability. In June 2007, a notice of disagreement (NOD) was received from the Veteran's representative on his behalf. A statement of the case (SOC) was issued in July 2008; and after additional evidence was received, the RO continued to deny the claims (as reflected in a September 2008 supplemental SOC (SSOC)). The Veteran filed a substantive appeal (via a VA Form 9, Appeal to the Board of Veterans' Appeals) in October 2008. After further development, the RO continued to deny the claims (as reflected in April 2009, February 2011, and June 2011 SSOCs). The appeal to the Board also arose from a June 2011 rating decision in which the RO, inter alia, denied compensation under 38 U.S.C.A. § 1151 for post operative right hand and ring finger Dupuytren's contracture residuals. The Veteran filed an NOD in June 2011. An SOC was issued in April 2012, and a May 2012 statement (via a VA Form 646, Statement of Accredited Representative in Appealed Case) from the Veteran's representative was accepted as a substantive appeal. In November 2012, the Board remanded the claims on appeal to the RO, via the Appeals Management Center (AMC) in Washington, DC, for additional development. After completing the requested development, the RO/AMC continued to deny these claims (as reflected in a February 2013 SSOC), and returned the matters to the Board for further consideration. As a final preliminary matter, and as discussed in the November 2012 remand, the Board notes that in various written statements, the Veteran has raised the issue of entitlement to service connection for a bilateral hip disability, to include as secondary to his service-connected foot disabilities. However, it does not appear that such claim has yet been addressed by the RO. As such, this matter is not properly before the Board, and is thus again referred to the RO for appropriate action. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate each claim herein decided has been accomplished. 2. No low back or knee disability was shown in service; there is no credible evidence of continuity of low back or knee symptomatology since service; low back and bilateral knee disabilities, to include arthritis, were first diagnosed many years after discharge from service; and the only competent. probative opinions to address the etiology of current low back and knee disabilities weigh against each claim. 3. While the Veteran has loss of motion and functioning in the right hand following March 2006 surgery and follow-up care for Dupuytren's contracture of the right hand and ring finger, such problems, even if the result of such surgery, were a foreseeable risk of this surgery. 4. The only competent, probative medical opinion to address the question of whether the Veteran has additional disability resulting from a March 2006 surgery and follow-up care for Dupuytren's contracture of the right hand and ring finger that was due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA physicians, or an event not reasonably foreseeable in connection with VA medical treatment weighs against the claim. CONCLUSIONS OF LAW 1. The criteria for service connection for low back disability, to include as secondary to bilateral pes planus and/or left foot bilateral plantar fibromatosis, are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309(a) 3.310 (2012). 2. The criteria for service connection bilateral knee disability, to include as secondary to bilateral pes planus and/or left foot bilateral plantar fibromatosis, are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309(a) 3.310 (2012). 2. The criteria for compensation benefits pursuant to the provisions of 38 U.S.C.A. § 1151 for additional disability resulting from a March 2006 surgery and follow-up care for Dupuytren's contracture of the right hand and ring finger are not met. 38 U.S.C.A. §§ 1151, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.358, 3.361 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Due Process Considerations The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 (West 2002 & Supp. 2012)) includes enhanced duties to notify and assist claimants for VA benefits. VA regulations implementing the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2012). Notice requirements under the VCAA essentially require VA to notify a claimant of any evidence that is necessary to substantiate the claim(s), as well as the evidence that VA will attempt to obtain and which evidence he or she is responsible for providing. See, e.g., Quartuccio v. Principi, 16 Vet. App. 183 (2002) (addressing the duties imposed by 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b)). As delineated in Pelegrini v. Principi, 18 Vet. App. 112 (2004), after a substantially complete application for benefits is received, proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim(s); (2) that VA will seek to provide; (3) that the claimant is expected to provide; and (4) must ask the claimant to provide any evidence in her or his possession that pertains to the claim(s), in accordance with 38 C.F.R. § 3.159(b)(1). The Board notes that, effective May 30, 2008, 38 C.F.R. § 3.159 has been revised, in part. See 73 Fed. Reg. 23,353-23,356 (April 30, 2008). Notably, the final rule removes the third sentence of 38 C.F.R. § 3.159(b)(1), which had stated that VA will request that a claimant provide any pertinent evidence in his or her possession. VCAA-compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO, to include the AMC). Id. Pelegrini, 18 Vet. App. at 112. See also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the VCAA notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. The VA's notice requirements apply to all five elements of a service connection claim: Veteran status, existence of a disability, a connection between a Veteran's service and the disability, degree of disability, and effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In this appeal, in a June 2006 pre-rating letter, the RO provided notice to the Veteran explaining what information and evidence was needed to substantiate the claims for service connection for low back and bilateral knee disabilities, to include on a secondary basis, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA. This letter also provided the Veteran with general information pertaining to VA's assignment of disability ratings and effective dates, as well as the type of evidence that impacts those determinations, consistent with Dingess/Hartman. A March 2011 pre-rating letter provided notice to the Veteran explaining what information and evidence was needed to substantiate his claim for benefits pursuant to the provisions of 38 U.S.C.A. § 1151, as well as what information and evidence must be submitted by the Veteran, and what information and evidence would be obtained by VA in adjudicating this claim. The record also reflects that VA has made reasonable efforts to obtain or to assist in obtaining all relevant records pertinent to the matter herein decided. Pertinent medical evidence associated with the claims file consists of the service treatment reports (STRs), VA and private treatment reports, and reports of VA examinations that included opinions as to the etiology of current low back and knee disabilities and the propriety of the March 2006 surgery and follow-up care for Dupuytren's contracture of the right hand and ring finger. The record also reflects attempts to obtain the additional records referenced in the November 2012 remand, with the Veteran requested by December 2012 letter, as directed in this remand, to submit the records of a Dr. Garzey. The Veteran did not submit such records or provide a properly executed release with this physician's address that would allow the RO to attempt to obtain these records. Additional VA treatment records, as requested in the November 2012 remand, dated through February 2013 were secured and associated with the Veteran's electronic (Virtual VA) file. Hence, the Board's prior remand directives have been fulfilled, to the extent possible, and no further RO action in this regard is necessary. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order); see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999). Also of record and considered in connection with the appeal are various oral and written statements provided by the Veteran, and by his representative, on his behalf. In particular, the Board hearing transcript reflects that the duties to fully explain the issues and to suggest the submission of evidence that may have been overlooked were fulfilled. See 38 C.F.R. § 3.103(c)(2) (2012); Bryant v. Shinseki, 23 Vet. App. 488 (2010). In summary, the duties imposed by the VCAA have been considered and satisfied with respect to the claims addressed herein. Through notice of the RO/AMC, the Veteran has been notified and made aware of the evidence needed to substantiate these claims, the avenues through which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claims herein adjudicated. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the appeal with respect to the claims remaining on appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters herein decided, at this juncture. See Mayfield v. Nicholson, 20 Vet. App. 537, 543 (rejecting the argument that the Board lacks authority to consider harmless error). See also ATD Corp. v. Lydall, Inc., 59 F.3d 534, 549 (Fed. Cir. 1998). II. Analysis When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) held that an appellant need only demonstrate that there is an "approximate balance of positive and negative evidence" in order to prevail. The Court has also stated, "It is clear that to deny a claim on its merits, the evidence must preponderate against the claim." Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. The Board notes, at the outset, that it has reviewed all of the evidence of record, to include in the Veteran's paper claims file and the Virtual VA. (The Virtual VA file contains VA clinical records dated through February 2013 that are documented to have been considered in the February 2013 SSOC). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claims. A. Service Connection Claims Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may be presumed, for certain chronic diseases, such as arthritis, which develop to a compensable degree (10 percent for arthritis) within a prescribed period after discharge from service (one year for arthritis), although there is no evidence of such disease during the period of service. This presumption is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Also, while the disease need not be diagnosed within the presumptive period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree. 38 C.F.R. § 3.307(c). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit recently clarified that the law providing for awards of service connection on the basis of continuity of symptomatology is limited to "chronic" diseases (such as arthritis) listed under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires: (1) competent evidence (a medical diagnosis) of current chronic disability; (2) evidence of a service-connected disability; and (3) competent evidence that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). Effective October 10, 2006, 38 C.F.R. § 3.310 was amended to implement the holding in Allen v. Brown, 7 Vet. App. 439(1995) for secondary service connection on the basis of the aggravation of a nonservice-connected disorder by service- connected disability. See 71 Fed. Reg. 52744 (2006). The amendment sets forth language that requires that a baseline level of severity of the nonservice-connected disease or injury must be established by medical evidence created before the onset of aggravation. The new regulation appears to place additional evidentiary burdens on claimants seeking service connection based on aggravation, specifically, in terms of establishing a baseline level of disability for the non-service-connected condition prior to the aggravation. Because the new law appears more restrictive than the old, and because the Veteran's appeal was already pending when the new provisions were promulgated, the Board will consider this appeal under the law in effect prior to October 10, 2006. See, e.g., Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003) (new regulations cannot be applied to pending claims if they have impermissibly retroactive effects). The Veteran's central argument with respect to his claims for service connection, to include in sworn testimony before the undersigned in June 2012 is that he developed low back and bilateral knee disabilities due to an altered gait pattern caused by his service-connected bilateral pes planus and/or bilateral plantar fibromatosis. As such, he asserts that entitlement to service connection for low back and bilateral knee disabilities is warranted as secondary to service connected foot disability. Summarizing the evidence with the applicable legal authority in mind, the STRs are silent for complaints, findings, or treatment for low back or knee problems. On separation examination in May 1971, clinical evaluation of the lower extremities and spine was reported as normal. A medical history was not recorded at that time. In a May 2001 VA nurse note, the Veteran reported having pain in his feet, knees, and hips and stated that he was attempting to gain disability benefits. In a general medicine note the same day, he indicated that his knees were beginning to hurt because of the way he walks secondary to his foot pain. The assessment included obesity, and he was encouraged to continue to lose weight. During a July 2001 orthopedic visit, his gait was observed as normal. During a March 2005 general medical examination, right knee crepitation was found on examination, but otherwise appeared within normal limits. In May 2006, the Veteran filed claims for service connection for back and knee disabilities as secondary to bilateral foot problems. (Service connection for disability involving the feet was ultimately granted after the submission of this application, with a February 2011 rating decision granting service connection for plantar fibromatosis of the left foot and bilateral pes planus. A June 2011 rating decision granted service connection for plantar fibromatosis of the right foot. Ten percent initial ratings were assigned for each of these disabilities by these rating decisions, and these ratings have remained in effect to the present time. Claims for initial ratings in excess of 10 percent for bilateral pes planus and left foot plantar fibromatosis were denied by a November 2012 Board decision issued simultaneously with the November 2012 remand.) Additional pertinent evidence includes the reports of a VA feet examination in November 2006, at which time general gait and heel and toe gait were reported as normal. On VA feet examination in January 2010, the Veteran was able to ambulate with and without his boots on with the use of his cane, he was able to clear both feet off the ground, gait was fairly stable with each heel clearing the toes of the opposite foot, and gait stride length was within normal limits. The examiner observed that the Veteran was able to flex his lower extremities at the knees and hips in order to wear his shoes, socks, and dress himself. During an August 2010 VA orthopedic surgery consultation, the Veteran reported a history of bilateral knee pain for 35 years since military service. In September 2010, the Veteran was afforded a VA joints examination to evaluate the nature and etiology of his claimed bilateral knee disability. He stated that his knee problems began in 2006. X-ray findings revealed mild, symmetrical degenerative changes noted most prominently involving the lateral compartments. The diagnosis was patellofemoral syndrome, bilateral knees with associated mild degenerative changes bilaterally. The examiner commented that the Veteran's bilateral knee disability was moderate in its severity and explained that it was an overuse condition that had no reasonable connection to his bilateral foot condition. The examiner noted that the foot condition did cause a mild change in his gait; however, this change was not sufficient to be the causative agent to the overuse condition affecting his knees. Therefore, the examiner opined that the Veteran's bilateral knee disability was less likely than not caused by or a result of his service. The Veteran was also afforded a VA spine examination on the same day in September 2010. He stated that his low back problems began in 2004. The impression of a lumbar spine x-ray was moderate spondylosis. After reviewing the claims file and conducting a physical examination, the diagnosis was moderate spondylosis of the lumbar spine. The examiner explained that the Veteran's back condition was degenerative in nature and was not caused by injury. A review of medical literature pointed to the condition being related to the normal aging process with external (i.e., lifestyle) factors as causative agents [being] quite controversial. Therefore, the examiner concluded, the current low back disability was not caused by or a result of his service connected foot disabilities. In commenting on the September 2010 VA joints and spine examinations, in the November 2012 remand, the Board noted that that the examiner did not provide a medical rationale supporting the opinion that the Veteran's bilateral knee disability was less likely than not caused by or a result of his service; did not provide a medical opinion regarding any direct relationship between the low back disability and military service; and did not provide medical opinions regarding whether the service-connected bilateral foot disabilities aggravated either the bilateral knee disabilities or low back disability. As such, the remand directed that the Veteran be afforded examinations of the low back and knees that included such opinions. The examinations requested in the November 2012 remand were accomplished in December 2012. The reports of these examinations document review of the Veteran's claims file, and following a review of the pertinent clinical history contain therein and physical examination of the lumbar spine and knees, the examiner concluded that it was less likely than not that the Veteran's current low back disability or bilateral degenerative joint disease of the knees was incurred in or caused by an in-service injury, event, or disease. As rationale for these opinions, the examiner noted the lack of any evidence of treatment of a low back or knee disability in the STRs. He also stated that low back strains were "extremely common," and that it was "not unusual" for someone the Veteran's age to have the mild degenerative joint disease in the knees that he currently has. The physician who conducted the December 2012 VA examinations of the low back and knees also concluded that it was less likely than not that such disability was caused or aggravated ("worsened beyond natural progression" as noted by the examiner) by the Veteran's bilateral pes planus and/or bilateral plantar fibromatosis. As stated rationale for this opinion, the examiner noted that the Veteran's foot disabilities caused pain but no major deformity that can scientifically be linked to the cause or progression of his low back or bilateral knee disabilities. The examiner explained that examination of the feet revealed plantar surface tenderness but no severe deformity and normal range of motion. He also remarked that the Veteran exaggerated symptoms that did not match objective findings as noted on prior examination and the current examination. First addressing the matter of direct service connection, the Board notes that the STRs, to include the separation examination report, are silent for a low back or knee disabilities, and the first medical evidence of any low back or knee disability is dated well over 25 years after service, with the Veteran himself only dating low back pain to 2004 and knee pain to 2006 during the September 2010 VA examination. With regard to a medical link between current low back disability and service, the opinion following the December 2012 VA examination was that such disability was not due to service. As for the knees, the opinions following the September 2010 and December 2012 VA examinations were also that such disabilities were not the result of service. Significantly, there are no contrary medical opinions as to the issue of direct service connection of record, and neither the Veteran nor his representative has identified or even alluded to the existence of any medical opinion that, in fact, supports the claims for direct service connection. Similarly, with respect to the matter of whether service connection for low back or knee disabilities may be granted as secondary to service connected foot disability, to include by way of aggravation, the only medical opinions addressing this question in its entirety specific to the Veteran are the negative opinions provided by the December 2012 VA examiner. In this regard, the Board acknowledges the medical references supplied the Veteran's representative in her May 2013 presentation to the Board discussing the impact between pes planus and knee and back pain. However, these extracts provide only general information, and none that pertains to the specifics of the Veteran's symptomatology and pathology. By contrast, the opinions rendered in December 2012 were based on both examination of the Veteran and review of the pertinent history specific to this Veteran. Therefore, the Board finds that the VA examiner adequately addressed the matter of secondary service connection on the basis of aggravation, and that these opinions constitute the only probative opinions on the question of etiological relationship between the disabilities for which service connection is claimed and service connected foot disability. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) ("It is the responsibility of the BVA to assess the credibility and weight to be given the evidence") (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). See also Guerrieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board). The Board acknowledges any assertions by the Veteran as to the occurrence of, and continuity of, low back and knee symptoms during service and up to the present time, to include the 35-year history of bilateral knee pain reported during an August 2010 VA orthopedic surgery consultation. The Veteran is certainly competent to report such symptoms. See e.g., Washington v. Nicholson, 19 Vet. App. 362 (2005); Layno v. Brown, 6 Vet. App. 465, 470 (1994). Here, however, the Board finds that any statements attempting to show continuity of symptomatology are not credible and, thus, cannot serve to controvert the VA examiner's opinions and provide a basis for a finding of service connection for a low back or bilateral knee disability on the basis of lay assertions, alone. As support for the finding that the Veteran has not credibly demonstrated continuity of back or knee symptoms since service, the Board notes that no knee or back disability was shown for well over 25 years after separation from service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). Also weighing against the Veteran's credibility is the fact that he only dated low back pain to 2004 and knee pain to 2006 during the September 2010 VA examination. In addition to, at least with respect to the knees, the Veteran's inconsistent statements as to when his symptoms began, the Board also questions the veracity of any continuity contentions given the fact that when the Veteran filed his initial claim for VA benefits in July 1997, he referred to flat feet as having been aggravated by service but did not at that time refer to a low back or knee disability as having been incurred in or aggravated thereby. The Board notes that silence in this initial application, when the Veteran is otherwise affirmatively speaking, would not be supportive of continuous problems with his back or knees since service. See White v. Illinois, 502 U.S. 346, 355-56 (1991) (noting that statements made for the purpose of medical diagnosis or treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive a proper diagnosis or treatment. See also Caluza v. Brown, 7 Vet. App. 498 (1995) (holding that a pecuniary interest is recognized as a factor which may affect the credibility of a claimant's statements). Accordingly, the Board finds that any assertions by the Veteran that he has had problems with his low back or knees since service are not credible. Furthermore, as for any assertions of the Veteran and/or his representative that there exists a medical nexus between current low back or knee disability and either \ service or service connected foot disability-the matters upon which these claims turn-the Board finds that such assertions do not provide persuasive support for the claims. In this regard, the Board emphasizes that the matters of the medical etiology of the Veteran's current low back and knee disabilities are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As neither the Veteran nor his representative is shown to have appropriate training and expertise, neither is competent to render a probative (i.e., persuasive) opinion as to the etiology of the currently diagnosed low back and left knee disabilities. See, e.g., Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); and Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). See also Bostain v. West, 11 Vet. App. 124, 127 (1998) and Routen v. Brown, 10 Vet. App. 183, 186 (1997) ("a layperson is generally not capable of opining on matters requiring medical knowledge"). As such, in this appeal, lay assertions of medical etiology have no probative value. For all the foregoing reasons, the Board concludes that the claims for service connection for low back and bilateral knee disabilities, each to include as secondary to bilateral pes planus and/or bilateral plantar fibromatosis, must be denied. In reaching these conclusions, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. B. 38 U.S.C.A. § 1151 Claim 38 U.S.C.A. § 1151 affords compensation benefits for a "qualifying additional disability" in the same manner as if the additional disability were service connected. The additional disability qualifies for compensation if the disability is not the result of the Veteran's willful misconduct, and the disability was caused by hospital care, medical or surgical treatment, or examination provided under the laws administered by VA. In order to constitute a "qualifying additional disability," the proximate cause of the additional disability must have been (1) carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the facility furnishing the care, treatment or examination or (2) an event not reasonably foreseeable. 38 U.S.C.A. § 1151 (West 2002). See also 38 C.F.R. § 3.361 (2012) . To determine whether a Veteran has an additional disability, VA compares his condition immediately before the beginning of the hospital care, medical or surgical treatment, or examination upon which the claim is based to his condition after such care, treatment, or examination has stopped. VA considers each involved body part separately. See 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care, medical or surgical treatment, or examination resulted in a Veteran's additional disability. Merely showing that he received care, treatment, or examination and that he has an additional disability does not establish cause. See 38 C.F.R. § 3.361(c)(1). Hospital care, medical or surgical treatment, or examination cannot cause the continuance or natural progress of a disease or injury for which the care, treatment, or examination was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. See 38 C.F.R. § 3.361(c)(2). Additional disability caused by a Veteran's failure to follow properly-given medical instructions is not caused by hospital care, medical or surgical treatment, or examination. See 38 C.F.R. § 3.361(c)(3). The proximate cause of disability is the action or event that directly caused the disability, as distinguished from a remote contributing cause. See 38 C.F.R. § 3.361(d). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a Veteran's additional disability, it must be shown that the hospital care, medical or surgical treatment, or examination caused his additional disability (as explained in 38 C.F.R. § 3.361(c)); and VA (i) failed to exercise the degree of care that would be expected of a reasonable health care provider; or (ii) furnished the hospital care, medical or surgical treatment, or examination without a Veteran's or, in appropriate cases, his representative's informed consent. See 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a Veteran's additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable, but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. See 38 C.F.R. § 3.361(d)(2). Summarizing the pertinent facts and contentions with the above legal criteria in mind, the record reflects that the Veteran presented for a VA plastic surgery consultation in May 2005 for evaluation of a Dupuytren's contracture of the right ring/small/middle finger. Following a physical examination, the plan was for a Dupuytren's contracture release with possible skin graft and K-wire fixation of the proximal interphalangeal joint. The consultation note indicated that PARQ (procedures, alternatives, risks, and questions) was completed with the Veteran and he gave his consent for the surgery. VA subsequently contracted with a private treatment provider to conduct the surgery. Private treatment records dated in March 2006 reflect that a lengthy PAR (procedures alternatives, and risks) was explained to the Veteran. Risks explained included bleeding; infection; swelling; scar; poor result; further surgery; failure to improve; tendon, vessel, and nerve damage; recurrence/further surgery; and other potential complications. The Veteran was given ample time to ask questions and his consent for surgery for Dupuytren's contracture of the right ring finger was obtained. A lengthy PARQ was completed again the next day during a history and physical prior to surgery, and the Veteran again gave his consent. He underwent an excision of Dupuytren's contracture from the carpal tunnel area past the proximal interphalangeal joint on the right ring finger and had a steroid injection to the right middle finger palm nodule. Follow-up VA treatment records beginning in April 2006 indicate that the Veteran was unhappy with the outcome of his right hand surgery, particularly due to a scar with numbness on his right palm. In October 2006, he stated that he could not lift with his right hand since his March 2006 surgery. He reported continued right hand soreness during an October 2010 VA plastic surgery consultation. The hand surgeon was not sure what was wrong; he indicated that the skin was tight in the palm; and there was no triggering, but it was sore along the flexor tendon sheath on resisted extension. During his June 2012 Board hearing, the Veteran testified that after his hand surgery, the incision became infected because the surgical wound was not treated properly, and as a result, he could not make a fist with his hand. He stated that his right hand was worse than prior to the March 2006 surgery. An examination to assist in the adjudication of the Veteran's claim for benefits pursuant to 38 U.S.C.A. § 1151 was requested in the November 2012 remand, and this examination was performed in December 2012. The reports from this examination indicate that the claims file was reviewed, and following a review of the pertinent history contain therein and interview and examination of the Veteran, the examiner concluded that it was less likely than not that the Veteran had additional hand disability as a result of the March 2006 surgery. It was further noted that surgery for a Dupuytren's contracture is "complicated with known risks," and that such risks include the possibility of revision surgery and loss of motion. The examiner explained that notes prior to the surgery explained that the risks of the surgery were discussed and that consent was given for the surgery. It was noted that the Veteran does have some loss of motion and functioning in the right hand but that this was a known risk of the procedure and "not due to carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care or medical or surgical treatment; or an event not reasonably foreseeable." As the VA examiner provided a detailed opinion, based on review of the claims file and examination and interview of the Veteran, the Board finds that the above opinion is probative as to the issue of whether as a result of the March 2006 surgery and follow up care, the Veteran incurred additional disability due to "carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of VA in furnishing the hospital care or medical or surgical treatment or an event not reasonably foreseeable." See Hayes, Guerrieri, supra. Thus, the only competent, persuasive opinion to address the 38 U.S.C.A. § 1151 claim weighs against the claim, and neither the Veteran nor his representative has presented, identified, or even alluded to the existence of any medical opinion that, in fact, supports this claim. Furthermore, to whatever extent the Veteran and/or his representative attempt(s) to establish the Veteran's entitlement to compensation under U.S.C.A. § 1151 on the basis of lay assertions, alone, the Board emphasizes that neither is shown to have training or expertise in the medical matters upon which this claim turns. See, Jandreau, Woehlaert, Bostain, Routen, supra. As such, in this appeal, lay assertions of medical etiology have no probative value. Under these circumstances, the Board finds that the claim of entitlement to compensation benefits pursuant to the provisions of 38 U.S.C.A. § 1151 for additional disability resulting from a March 2006 surgery and follow-up care for Dupuytren's contracture of the right hand and ring finger must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against this claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for a low back disability, to include as secondary to bilateral pes planus and/or bilateral plantar fibromatosis, is denied. Service connection for a bilateral knee disability, to include as secondary to bilateral pes planus and/or bilateral plantar fibromatosis, is denied. Compensation benefits pursuant to the provisions of 38 U.S.C.A. § 1151 for additional disability resulting from a March 2006 surgery and follow-up care for Dupuytren's contracture of the right hand and ring finger is denied. ____________________________________________ JACQUELINE E. MONROE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs