Citation Nr: 1320294 Decision Date: 06/24/13 Archive Date: 07/02/13 DOCKET NO. 07-27 922 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Fort Harrison, Montana THE ISSUE Entitlement to service connection for a bilateral ankle disability, including as secondary to service-connected bilateral heel spurs. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD T. Sherrard, Counsel INTRODUCTION The Veteran, who is the Appellant in this case, had active service in the U.S. Air Force from December 1977 to December 1981, and in the Army National Guard from June 2004 to December 2005. The Veteran also had service in the Air Force Reserve from December 1981 to October 1983, and in the Montana National Guard from June 2003 to June 2004, with various periods of active duty for training (ADT) and inactive duty for training (IADT). This matter comes before the Board of Veterans' Appeals (BVA or Board) from a November 2006 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this claim for further development in June 2011 and November 2011. As discussed below, the development requested has been completed, and the claim is now appropriate for appellate review. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. The Board referred the issue of entitlement to service connection for pain in multiple joints, including the knees and elbows, claimed as due to undiagnosed illness to the Agency of Original Jurisdiction (AOJ) for initial adjudication in its November 2011 remand. However, it does not appear that the AOJ has had an opportunity to adjudicate the claim. Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. The Veteran did not incur a bilateral ankle injury or disease during active service, symptoms of a bilateral ankle disability were not chronic in service, symptoms of a bilateral ankle disability have not been continuous since service separation, and the bilateral ankle disability is not related to active service. 2. Symptoms of ankle arthritis did not manifest to a compensable degree within one year of separation. 3. The Veteran's bilateral ankle disability is not causally related to or permanently worsened by the service-connected bilateral foot disabilities. CONCLUSION OF LAW The criteria for service connection for a bilateral ankle disability have not been met. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1113, 1131, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. The Board acknowledges that where a veteran who served for ninety days or more during a period of war (or during peacetime service after December 31, 1946) develops certain chronic diseases, such as arthritis, to a degree of 10 percent or more within one year from separation from service, such diseases may be presumed to have been incurred in service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). However, since arthritis has not been diagnosed in this case, the claimed bilateral ankle condition at issue is not a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.309(b) (requiring continuity of a condition after service if chronicity is not found in service) does not apply to the claimed condition. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The United States Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disability. See 38 C.F.R. § 3.310(a). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. See 38 C.F.R. § 3.310(a); Harder v. Brown, 5 Vet. App. 183, 187 (1993). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995). "Aggravation" is defined for this purpose as a chronic, permanent worsening of the underlying condition, beyond its natural progression, versus a temporary flare-up of symptoms. Id. To prevail on the theory of secondary service causation, generally, the record must show (1) medical evidence of a current disability, (2) a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). Effective from October 10, 2006, 38 C.F.R. § 3.310 was amended. See 71 Fed. Reg. 52,744 (2006). The new regulation appears to place additional evidentiary burdens on claimants seeking service connection based on aggravation, specifically in terms of requiring the establishment of a baseline level of disability for the non-service-connected condition prior to the claimed aggravation. Regardless of whether the case is considered under the old or new regulation, based upon the facts in this case, neither version is more favorable, and the regulatory change does not affect the outcome herein. In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." See Layno, 6 Vet. App. at 469; 38 C.F.R. § 3.159(a)(2). The Court has emphasized that when a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept. 14, 2009). Lay statements may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of a veteran's claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. The Board has reviewed all the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by a veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). The Veteran in this case contends that he has a current bilateral ankle disability that was either incurred during active service or caused or aggravated by his service-connected bilateral heel spurs. Specifically, with regard to direct service incurrence, he avers that he has bilateral ankle pain and instability caused by repetitive jumping in and out of supply vehicles, and that the ankle disability was both further aggravated and masked by wearing boots throughout his deployment during active service. The Board will consider whether the bilateral ankle disability is directly related to service or caused or aggravated by the service-connected heel spurs. After a review of all the evidence of record, lay and medical, the Board finds that although the Veteran had ankle pain beginning during active service in November 2005 and continuing through and after service separation in 2006, the weight of the evidence demonstrates that the Veteran did not incur a chronic bilateral ankle disability during active service, and that the weight of the evidence demonstrates that symptoms of a bilateral ankle disability were not chronic in service. In this regard, the Board notes that VA does not generally grant service connection for symptoms alone, without an identified basis for those symptoms. VA needs to identify a disability, not symptoms of a disability. In this case, although the Veteran had ankle pain that began during active service, it resolved in 2006 and no underlying cause for the pain was ever identified. The Veteran's service treatment records from his first period of active service from December 1977 to December 1981 are entirely negative for complaints, reports, symptoms, findings, treatment, or diagnosis of a bilateral ankle disability. An August 1981 note indicates that a separation physical examination was conducted and that there were no abnormal findings. Moreover, the Veteran does not allege that his bilateral ankle disability began during or was caused by this first period of active service. Next, with regard to the Veteran's second period of active service from June 2004 to December 2005, the Board notes that a June 2003 National Guard enlistment examination is negative for any findings or diagnosis pertinent to the ankles. Indeed, clinical evaluation of the lower extremities and feet is marked as "normal," and the Veteran checked "no" next to "arthritis," "foot trouble," "impaired use of feet," and "swollen or painful joints." A March 2004 pre-deployment examination report is also negative for any report or findings of ankle problems, as is an October 2005 post-deployment examination report. At the latter examination, the Veteran specifically denied swollen, stiff, or painful joints, and answered no when asked if he had suffered from any injury or illness while on active duty for which he did not seek medical care. Further, he reported bilateral heel pain with plantar fasciitis, but did not report any ankle pain. His report of heel pain at the post-deployment examination without mention of ankle pain is highly probative evidence against his claim that his ankle pain began during his deployment. The first documented mention of ankle pain is found in a November 2005 service treatment record which indicates that the Veteran reported pain in his ankles and heels that he said developed five months prior. The Board notes that this report of inception contradicts the Veteran's failure to report any ankle pain at the October 2005 examination one month prior. In November 2005, the Veteran stated that his job in a supply troop required repetitive climbing up onto and jumping down from supply vehicles. He denied any specific injury or trauma, however. He also believed that the boots he wore contributed to the problem. He stated his ankles hurt sometimes while walking on rocks. He denied having suffered any ankle sprains. On physical examination, there was no effusion, rubor, calor, or ecchymosis. There was tenderness of the tensor fasciae latae (TFL) muscle bilaterally. There was no ligament laxity, and a negative drawer test bilaterally. The examining clinician assessed multiple joint pains, probably all due to overuse. At a follow-up appointment later that month (in November 2005), the clinician noted that x-ray studies of the ankles were normal, and continued assessment of overuse injuries to the elbows, knees, and ankles. The Veteran was referred for physical therapy to address his ankle and heel pain, which he began in late November 2005 and continued through March 2006 (after separation from active duty in the National Guard). Following separation from active service, in March 2006, the physical therapist noted that although the Veteran had engaged in a physical therapy program for the heels and ankles, heel and ankle pain continued to be a problem. Specifically, the Veteran had intermittent ankle pain throughout the day that was at its worst first thing in the morning. She noted that therapy had included various modalities, manual techniques, ultrasound, and exercise, with very minimal relief. She concluded that additional physical therapy would not be warranted at that time, as all avenues of therapy had been tried. The therapist referred the Veteran to see Dr. F. for evaluation. Notably, the Veteran was afforded a VA examination in February 2006, following service separation, at which he did not report any ankle pain or other ankle problems, despite reporting multiple other disabilities which he believed to be service-related. In addition, physical examination of the ankles at that time revealed full range of motion, and x-ray studies were normal. In April 2006, the Veteran was seen by Dr. F., and reported an 18 month history of bilateral ankle pain and stiffness. The Board notes that the Veteran's history of 18 months of ankle symptoms differs yet again from the histories he provided in October 2005 (when he did not report any ankle problems) and November 2005 (when he reported 5 months of ankle pain). He stated the symptoms were worse after periods of rest, and improved with activity. He denied any gait abnormality or difficulty walking. On physical examination, pain was elicited by motion of the ankle, but no instability of the ankles was noted. Specifically, there was pain on dorsiflexion to the anterior ankles. The doctor noted that x-ray studies from November 2005 revealed a small anterior impingement exostosis, right greater than left. Dr. F. assessed joint pain localized in the ankle. A June 2006 VA treatment note indicates the Veteran reported continued bilateral ankle pain. No treatment or diagnosis was rendered at that time, however. In October 2006, the February 2006 VA examiner again evaluated the Veteran and wrote an addendum to her report, in which she noted that, in February 2006, there was no claim for the bilateral ankles, but that the ankles were x-rayed and tested to assist in evaluating the complaints of severe bilateral foot pain. The VA examiner further noted that review of the claims file showed that the Veteran reported ankle pain in March 2006, weeks after the February 2006 VA examination, and that examination of the ankles in February 2006 showed full range of motion and negative x-ray studies. Based on this, the VA examiner concluded that the ankles were not a contributing factor to the complaints of bilateral foot pain. The next chronological documentation of ankle pain is from 2010. In sum, although the Veteran's service treatment records show that he reported bilateral ankle pain beginning in November 2005 and continuing through June 2006, no underlying disability was ever identified or diagnosed, and the pain appears to have resolved in 2006, as there is no further documentation of treatment for ankle pain until 2010, four years later. With regard to Dr. F.'s notation that the November 2005 x-ray study revealed impingement exostosis of the ankles, the June 2011 VA examiner noted that anterior impingement exostosis is manifested by painful limitation of dorsiflexion, swelling, stiffness, and limping. However, VA treatment records did not show any complaints or symptoms of painful limitation of dorsiflexion, swelling, stiffness, or limping. Moreover, the VA examiner noted that there was no radiologic or podiatric diagnosis of anterior impingement exostosis from 2005 to the time of the present examination. Thus, while impingement exostosis was identified by x-ray study during active service in November 2005, there were no accompanying symptoms of such a disability, and the Veteran's ankle pain was not attributed to the impingement exostosis. In fact, despite this finding, the diagnosis was joint pain in the ankle. Thus, the Board finds that the weight of the evidence demonstrates that there was no chronic bilateral ankle disability during any period of active service, and that symptoms of a bilateral ankle disability were not unremitting during active service. The Board next finds that the weight of the evidence demonstrates that symptoms of a bilateral ankle disability have not been continuous since separation from active service in December 2005. As noted above, the Veteran reported ankle pain beginning in November 2005 and continuing until June 2006. Thereafter, the evidence of record does not show any complaints, diagnosis, or treatment for ankle symptoms until January 2010, when the Veteran was diagnosed with tibial tendinitis in the context of complaining of foot pain rather than ankle pain. Further, there is no indication that the Veteran related any ankle pain to military service, which is highly probative evidence against his current claim. The absence of post-service complaints, findings, diagnosis, or treatment for over four years after service separation until 2010 (or nearly four years after the ankle pain resolved in June 2006) is one factor that tends to weigh against a finding of unremitting symptoms of a bilateral ankle disability after service separation. See Buchanan, 451 F.3d 1336 (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible). The Board also finds that the weight of the evidence demonstrates that bilateral ankle arthritis did not manifest to a compensable degree within one year of service separation. The weight of the evidence demonstrates no arthritis symptoms during the one year period after service, and no diagnosis or findings of arthritis of any severity during the one year post-service presumptive period. See 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010 (2012) (degenerative and traumatic arthritis established by X-ray findings is rated on the basis of limitation of motion under the appropriate diagnostic codes for the joint involved, and can be assigned a 10 percent evaluation if limitation of motion is noncompensable). Indeed, the evidence does not demonstrate a current diagnosis of ankle arthritis. For these reasons, the Board finds that arthritis did not manifest to a compensable degree within one year of service separation; therefore, the presumptive provisions for arthritis are not applicable in this case. 38 C.F.R. §§ 3.307, 3.309 (2012). With regard to the Veteran's more recent assertions made as part of the current compensation claim that he has had bilateral ankle symptoms since separation from service in December 2005, the Board finds that, while the Veteran is competent to report the onset of ankle symptoms, his recent reports of unremitting ankle symptoms since service are outweighed by the other, more contemporaneous, lay and medical evidence of record, both in service and after service, and are not reliable. See Charles v. Principi, 16 Vet. App. 370 (2002). The Board finds that the statements of the Veteran as to unremitting ankle symptoms after service are not accurate because they are outweighed by other evidence of record that includes the more contemporaneous service treatment records which are negative for the onset of a bilateral ankle disability, the lack of any post-service documentation of treatment or diagnosis of a bilateral ankle disability for over four years after service separation until 2010 (and even then, the diagnosis of tibial tendinitis was made incidental to complaints of foot pain rather than ankle pain), the Veteran's failure to both report ankle problems or relate any ankle problems to military service while seeking treatment in 2010, and his claim for service connection for multiple disabilities in November 2005 with no mention of ankle problems. The Board acknowledges that symptoms, not treatment, are the essence of any evidence of continuity of symptomatology (Savage v. Gober, 10 Vet. App. 488, 496 (1997)); however, here, the Veteran filed a claim for service connection in November 2005, but did not mention any ankle symptoms at that time. This suggests to the Board that there was no pertinent ankle symptomatology at that time. While inaction regarding filing a claim is not necessarily indicative of the absence of symptomatology, where, as here, a veteran takes action regarding other claims, it becomes reasonable to expect that the Veteran is presenting all issues for which he is experiencing symptoms that he believes are related to service. In other words, the Veteran demonstrated that he understood the procedure for filing a claim for VA disability compensation, and he followed that procedure in other instances where he believed he was entitled to those benefits. In such circumstances, it is more reasonable to expect a complete reporting than for certain symptomatology to be omitted. Thus, the Veteran's inaction regarding a claim for a bilateral ankle disability, when viewed in the context of his action regarding other claims for compensation, may reasonably be interpreted as indicative of the Veteran's belief that he did not sustain a bilateral ankle disability in service, or the lack of ankle symptomatology at the time he filed the claim, or both. The Board further finds that the weight of the evidence demonstrates that the Veteran's currently diagnosed bilateral ankle disability is not related to his active service. In the December 2011 VA examination addendum report, which weighs against the Veteran's claim, the examiner opined that the Veteran's tibial tendinitis diagnosed in January 2010 was less likely as not related to active service, reasoning that, if tibial tendinitis is left untreated, the pain will worsen and the patient would begin to lose the foot's arch. Eventually, the VA examiner stated the patient would be unable to exert pressure on the foot and would be in an immense amount of pain when trying to do so. In this case, however, the VA examiner noted that treatment records from the past 11 months did not show a single entry regarding tibial tendinitis. In fact, the examiner noted that the Veteran had 32 visits to the VA Medical Center since January 2010 (when he was first diagnosed with tibial tendinitis), and that none of the notes from those visits contained a diagnosis of tibial tendinitis or complaints of heel or ankle pain. Further, as noted above, the June 2011 VA examination showed a normal physical evaluation of the ankles, with no finding of a current disability. The June and December 2011 VA opinions are of significant probative value because they are factually accurate, as it appears the VA examiner was informed of the relevant evidence in this case, relied on accurate facts, and gave fully articulated opinions that are supported by a sound reasoning, citing to specific medical records. Based on the evidence of record, the weight of the competent evidence demonstrates no relationship between the Veteran's bilateral ankle disability and his military service, including no credible evidence of either a relevant in-service disease or injury, unremitting symptoms of ankle disabilities during active service, or unremitting symptomatology of ankle disabilities following service separation. Therefore, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against the claim for service connection for bilateral ankle disabilities, and outweighs the Veteran's more recent contentions regarding in-service chronic ankle problems and post-service ankle problems. The Veteran is also contending that his bilateral ankle disability was caused or aggravated by his service-connected heel spurs. To prevail on the issue of secondary service causation, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin, 11 Vet. App. at 512; Reiber, 7 Vet. App. at 16-17. Service connection has been granted for plantar fasciitis with heel spurs in both the right and left feet from December 2005. However, the Board finds that the weight of the evidence demonstrates no relationship between the Veteran's bilateral ankle disability and his service-connected foot disabilities. In the December 2011 VA examination report, discussed above, the VA examiner also opined that the bilateral ankle conditions were not caused or aggravated by his service-connected heel spurs, which were an incidental finding made in 2005. The same rationale was provided for this opinion as for the examiner's opinion that the current ankle disability was not directly related to active service. The 2011 VA opinion is competent and probative medical evidence because it is factually accurate, and is supported by an adequate rationale. The VA examiner was informed of the pertinent evidence, reviewed the claims file, interviewed and examined the Veteran, and fully articulated the opinion. There are no contrary medical opinions of record, nor does the medical evidence otherwise suggest a relationship between the Veteran's bilateral ankle disability and his service-connected foot disabilities. Regarding the Veteran's statements as to the cause of his bilateral ankle pain, the Board recognizes that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson, 581 F.3d at 1316 (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau, 492 F.3d 1372). However, in this case, the cause of the Veteran's bilateral ankle pain involves a complex medical etiological question because it deals with the origin and progression of the Veteran's musculoskeletal system, and disorder of such internal and complex disease process is diagnosed primarily on clinical findings and physiological testing. The Veteran is competent to relate symptoms of bilateral ankle pain that he experienced at any time, but is not competent to opine on whether there is a link between any currently diagnosed bilateral ankle disorder and a service-connected disability, including the bilateral heel spurs, because such diagnosis requires specific medical knowledge and training. See Rucker, 10 Vet. App. at 74 (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). For these reasons, the Board finds that weight of the lay and medical evidence that is of record outweighs the Veteran's more recent contentions regarding the relationship between his bilateral ankle pain and service-connected foot disabilities. Based on the foregoing, the Board finds that the weight of the evidence is against a finding that the Veteran's bilateral ankle disability was caused or aggravated by any service-connected disability. For these reasons, service connection for a bilateral ankle disability must be denied. As the preponderance of the evidence weighs against the Veteran's claim for service connection for a bilateral ankle disability, the benefit of the doubt doctrine is not applicable, and the claim for service connection must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. 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, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). The notice requirements of VCAA require VA to notify the claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. The Board notes that a "fourth element" of the notice requirement requesting the claimant to provide any evidence in the claimant's possession that pertains to the claim was removed from the language of 38 C.F.R. § 3.159(b)(1). See 73 Fed. Reg. 23,353-356 (April 30, 2008). The Court issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In a timely March 2006 letter, the RO provided notice to the Veteran regarding what information and evidence is needed to substantiate a claim for service connection, what information and evidence must be submitted by the Veteran, and what information or evidence VA will attempt to obtain. A separate March 2006 letter described how VA determines disability ratings and effective dates. The Board is also satisfied VA has made reasonable efforts to obtain relevant records and evidence. Specifically, the information and evidence that has been associated with the claims file includes the Veteran's service treatment records, post-service VA and private treatment records, a VA opinion, and the Veteran's statements. VA opinions were obtained in June and December 2011 with regard to the question of whether the Veteran's current bilateral ankle disability was related to either active service or to a service-connected disability. To that end, when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the 2011 VA opinions obtained in this case are adequate as to the question of whether the Veteran's bilateral ankle disability is related to active service or to a service-connected disability. The opinions were predicated on a full reading of the private and VA medical records in the Veteran's claims file, as well as a thorough physical examination and interview of the Veteran. The VA nexus opinions considered all of the pertinent evidence of record, to include VA treatment records, comprehensive physical examinations, and the statements of the Veteran, and provide a complete rationale for the opinions stated, relying on and citing to the records reviewed. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion with respect to the claim decided herein has been met. 38 C.F.R. § 3.159(c)(4). Notably, the Veteran has not identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). ORDER Service connection for a bilateral ankle disability is denied. ____________________________________________ MICHELLE L. KANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs