Citation Nr: 1322804 Decision Date: 07/17/13 Archive Date: 07/24/13 DOCKET NO. 07-26 471 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to service connection for asthma, to include bronchial asthma and bronchitis. 2. Entitlement to service connection for pes planus. WITNESSES AT HEARING ON APPEAL Appellant and C.J. ATTORNEY FOR THE BOARD Jeanne Schlegel, Counsel INTRODUCTION The Veteran had active military duty from February 25, 1969 to March 21, 1969. This matter comes before the Board of Veterans' Appeals (Board) on appeal from April 2007 (asthma) and April 2010 (pes planus) rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. In August 2008, the Veteran testified before the undersigned Veterans Law Judge at a Board video-conference hearing in reference to the service connection claim for asthma only. A transcript of the hearing has been associated with the file. The service connection claim for asthma was previously before the Board in March 2009, at which time the Board reopened the claim based on the presentation of new and material evidence, and remanded it for additional evidentiary development. As will be further explained herein, there has been substantial compliance with the actions requested in that remand and the case has returned to the Board for appellate consideration. See also D'Aries v. Peake, 22 Vet. App. 97 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board's remand directives is required). The record reflects that the Veteran had requested a Board hearing in conjunction with his service connection claim for pes planus; he elected to cancel a Board hearing scheduled for December 2012. In April 2013, documentation was added to the file confirming the Veteran's request to cancel the hearing. A July 2013 review of the Virtual VA electronic records storage system does not reveal any additional documents not currently associated with the paper claims file. FINDINGS OF FACT 1. There is clear and unmistakable medical evidence that the Veteran entered active duty with pre-existing asthma. 2. There is clear and unmistakable medical evidence that the Veteran's active duty did not aggravate his pre-existing asthma. 3. Pes planus was identified and noted on an examination report for entrance into active duty dated in late February 1969. 4. Pes planus did not increase in severity during or as a result of the Veteran's less than one month of active service. CONCLUSIONS OF LAW 1. The criteria for the establishment of service connection for asthma, to include bronchial asthma and bronchitis, are not met. 38 U.S.C.A. §§ 1110, 1153, 1154, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§3.102, 3.159, 3.303, 3.304, 3.306 (2012). 2. The criteria for the establishment of service connection for pes planus are not met. 38 U.S.C.A. §§ 1110, 1153, 1154, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§3.102, 3.159, 3.303, 3.304, 3.306 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000, 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The RO informed the Veteran of VA's duty to assist him in the development of evidence pertinent to his service connection claims in letters dated in July 2006 (asthma), and November 2009 (pes planus), wherein he was advised of the provisions relating to the VCAA. Specifically, the Veteran was advised that VA would assist him with obtaining relevant records from any Federal agency, which may include medical records from the military, from VA hospitals (including private facilities where VA authorized treatment), or from the Social Security Administration. With respect to private treatment records, the letter informed the Veteran that VA would make reasonable efforts to obtain private or non-Federal medical records, to include records from State or local governments, private doctors and hospitals, or current or former employers. Furthermore, the VA included copies of VA Form 21-4142, Authorization and Consent to Release Information, which the Veteran could complete to release private medical records to the VA. The notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (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. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Specifically, this information must include notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. This specific notification was furnished in this case pursuant to the 2006 and 2009 duty to assist letters. The Board also finds that all of the relevant facts have been properly developed, and that all available evidence necessary for an equitable resolution of the claims on appeal has been obtained. The Veteran's service treatment records (STRs) and post-service VA and private treatment records and opinions were obtained. In addition lay statements have also been added to the file along with contentions, arguments, and testimony provided by the Veteran. VA's duty to assist also includes obtaining an examination and medical opinion when necessary to make an adequate determination. See Duenas v. Principi, 18 Vet. App. 512 (2004). During the appeal period, VA examinations and opinions were obtained for the file in June 2012, addressing the service connection claims in appellate status. The Veteran has not maintained that these examination reports are inadequate, or fail to address the pertinent arguments raised. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011), (in the absence of a challenge to the adequacy of the examination, the Board is not required to explicitly explain why each medical opinion is adequate). Accordingly, the Board finds that under the circumstances of this case, VA has satisfied the notification and duty to assist provisions of the VCAA and that no further actions need be undertaken on the Veteran's behalf. See 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c)-(e). The Board finds that as to the claims being decided herein on appeal, all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). Significantly, the Veteran has not specifically identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance is required to fulfill VA's duty to assist the appellant in the development of the claims. 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). Service Connection Claims Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d) A veteran is presumed to have been sound upon entry into the military, except as to conditions noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. § 1111. By "clear and unmistakable evidence" is meant that which cannot be misunderstood or misinterpreted; it is that which is undebatable. Vanerson v. West, 12 Vet. App. 254 (1999). In determining whether there is clear and unmistakable evidence to rebut the presumption of soundness, all evidence of record must be considered, including post service medical opinions. Harris v. West, 203 F.3d 1347 (Fed. Cir. 2000); Adams v. West, 13 Vet. App. 453 (2000). An injury or disease that has been determined to be preexisting will then be presumed to have been aggravated by service where there is an increase in the severity of the disability during service. The burden to show no aggravation of a pre-existing disease or disorder during service lies with the government. Cotant v. Principi, 17 Vet. App. 117, 131 (2003). However, the presumption of aggravation is rebutted where there is a specific finding that the increase is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. In deciding an aggravation claim, after having determined the presence of a preexisting disability, the Board must determine whether there has been any measurable worsening of the disability during service and whether this worsening constitutes an increase in disability. Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). Temporary or intermittent flare-ups of the preexisting condition during service are not sufficient to be considered aggravation unless the underlying condition, as contrasted to symptoms, has worsened. Crowe v. Brown, 7 Vet. App. 238, 247-48 (1994); Hunt v. Derwinski, 1 Vet. App. 292, 296-97 (1991). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during and subsequent to service. 38 C.F.R. § 3.306(b). Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under the laws administered by VA. VA shall consider all information and medical and lay evidence of record. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 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, 1 Vet. App. at 54. A. Asthma The STRs include a February 1968 enlistment examination report reflecting that the Veteran was determined to be disqualified for enlistment purposes due to being overweight. Clinical evaluation of the lungs, chest and heart was normal. The Veteran acknowledged having asthma; a notation was made on the examination report to the effect that that this claim was made so that the Veteran could avoid the draft. It appears that the Veteran attempted re-enlistment a year later. In conjunction with that re-enlistment, a February 24, 1969 statement from a private doctor indicated that the Veteran was physically fit for service and certified that the Veteran had not been treated for asthma or hay fever, but had treated been treated for common colds only. A notation on the February 1968 examination report dated February 25, 1969, indicated that the Veteran had no asthma. Also apparently added to the February 1968 examination report in 1969, were the Veteran's comments to the effect that he had previously been rejected for military service due to asthma. Upon further evaluation conducted on February 27, 1969, it was reported that a chest X-ray film was normal and asthma was not identified as a defect or condition existing on enlistment. The Veteran's immunization record is entirely negative except for a mention of Sulfasoxazole tabs given for 2 days beginning on February 25, 1969. When evaluated on March 4, 1969, the Veteran reported that he had suffered from asthma and hay fever since childhood, for which he frequently used oral medications. Questionable asthma by history and minimal objective bronchospasms after vigorous exercise was diagnosed. A March 12, 1969 Medical Board report indicates that a diagnosis of bronchial asthma had been established and that it was recommended that the Veteran be separated from service. The report indicated that he was admitted to the sick list on March 7, 1969. It was also mentioned that the Veteran served for 15 days before it was determined that he was to be discharged due to erroneous enlistment due to bronchial asthma, which was found to have existed prior to service and was not aggravated by service. The file contains a private medical statement of Dr. B.E. dated in November 1996, indicating that he had treated the Veteran for severe asthma since January 1996. In July 1997, a private medical statement was received from Dr. J. H. indicating that since 1982, the Veteran had been followed for conditions including asthma. In January 1998, a medical statement was received from Dr. W.S. indicating that the Veteran had been under his care for asthma since 1979, then crossed out to read 1971. In July 1998, Dr. W.S. provided a second statement to this effect. After the Veteran's service connection claim for asthma was denied by the Board in August 1999 based on the failure to present new and material evidence to reopen it, he filed to reopen the claim in July 2006. In support of the claim, he provided a statement of Dr. J.H.D. dated in August 2005. The doctor indicated that the Veteran had a life-long history of bronchial asthma which had been treated by several physicians. It was noted that symptoms were relatively mild and apparently controlled well with medication. It was noted that on service enlistment, the Veteran gave a medical history of asthma, but it was not considered disqualifying. The doctor indicated that during the course of military service, "with exposure to varying weather patterns, having to perform in the heat, wet weather, and exposure to dust, the barracks environment and incompatible dietary substances, his asthma was severely aggravate." The doctor added that since his discharge, the Veteran had continued to experience significant respiratory difficulty. It was concluded that the Veteran unquestionably had documented bronchial asthma, which by history, was aggravate by military service. The Veteran presented testimony at a Board video conference hearing held in August 2008. He indicated that during his brief period of service, he had an asthma attack for which he was hospitalized for a few days. He indicated that he had to do a lot of running and exercises during training, and also received a shot in the arm, which may have triggered the attack. In a March 2009 Board decision, it was determined that new and material evidence was received to reopen the service connection claim for asthma, and the claim was remanded for additional evidentiary development. Specifically, a VA examination and opinion was requested to identify the nature of the Veteran's respiratory disorder and to address whether in such event that it pre-existed service, it was permanently aggravated therein or as a result thereof. In a September 2011 statement, the Veteran contended that although he only had 27 days of active service, when he received multiple shots in 1968 during basic training, his asthma immediately emerged from a long period of quiescence since childhood and it had never returned to its premorbid baseline level. He indicated that he did not know what shots he had been given, but that these could have included antibiotics. He also supplied a copy of a page from The Merck Manual discussing occupational asthma, and indicating that occupational allergens may include antibiotics. A VA respiratory examination was conducted in June 2012, at which time asthma was diagnosed. Following a review of the claims folder, the VA examiner opined that it was less likely than not that asthma was caused or worsened by service. It was explained that even given factors in service such as cold air and exercise, these are characteristics of asthmatic bronchospasm which do not cause permanent worsening. The examiner clarified that these factors are not toxic agents capable of permanent worsening or damage to the bronchial mucosa. Analysis Initially, the Board notes that the evidence of record clearly and unmistakably establishes that the Veteran's asthma pre-existed his active military service. In this regard, every veteran shall be taken to have been in sound condition when examined, accepted and enrolled for service, except as to defects noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the disease or injury existed before acceptance and enrollment and was not aggravated by service. 38 U.S.C.A. §§ 1111, 1137. The term "noted" denotes only such disorders that are recorded in examination reports. The existence of disorders prior to the active military service reported by the veteran as medical history do not constitute a notation of such disorders, but it will be considered together with all of the other evidence in question as to the commencement of the disease or disorder. 38 C.F.R. § 3.304(b)(1). Determinations of whether a disorder pre-existed the active military service should be based on a thorough analysis of the evidentiary showing and careful correlation of all medical facts, with due regard to manifestations, clinical course and character of the particular injury or disease or residuals thereof. Id. In this case, on February 1968 and 1969 military entrance examination reports, the Veteran was found to have normal lungs and a normal chest X-ray. On the Report of Medical History, the Veteran marked that he had a history of asthma. In late February 1969, the Veteran was inducted into the Army. Within approximately the first week of service (March 4, 1969), the Veteran was treated for questionable asthma. At that time, the Veteran gave a history of asthma and hay fever since childhood, for which he used oral medications frequently. Thus, the Board finds that the evidence of record establishes that there is clear and unmistakable medical evidence that the Veteran entered active duty with pre-existing asthma. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304. In this regard, an injury or disease that has been determined to have pre-existed the military service will then be presumed to have been aggravated by the active military service, where there is an increase in the severity of the disorder during the active military service. The burden to show no aggravation of a pre-existing disease or disorder during the military service lies with the government. Cotant v. Principi, 17 Vet. App. 117, 131 (2003). The claimant is not required to show that the disease or injury increased in severity during the active military service. Instead, VA must show by clear and unmistakable evidence that the pre-existing disease or disorder was not aggravated during the active military service. See VAOPGCPREC. 3- 03 (July 16, 2003) (69 Fed. Reg. 29178 (2004). However, the presumption of aggravation is rebutted where there is a specific finding that the increase is due to the natural progress of the disease. 38 U.S.C.A. 1153; 38 C.F.R. § 3.306. In deciding an aggravation claim, after having determined the presence of a pre-existing disorder, the Board must determine whether there has been any measurable worsening of the disorder during the active military service and whether this worsening constitutes an increase in the disorder. Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). Temporary or intermittent flare-ups of the pre-existing disorder during the active military service are not sufficient to be considered aggravation unless the underlying disorder, as contrasted to symptoms, has worsened. Crowe v. Brown, 7 Vet. App. 238, 247-48 (1994); Hunt v. Derwinski, 1 Vet. App. 292, 296-97 (1991). Aggravation may not be conceded where the disorder underwent no increase in severity during the active military service on the basis of all the evidence of record pertaining to the manifestations of the disorder prior to, during and subsequent to the active military service. 38 C.F.R. § 3.306(b). Here, as previously mentioned, the Veteran's STRs document that he was admitted to the hospital during service; having gone on the sick list as of March 7, 1969; approximately 10 or 11 days after his enlistment date. On March 12, 1969, he was underwent a Medical Board review, at which time it was determined that the Veteran be discharged for erroneous enlistment, 15 days after his enlistment. In March 1969, the Medical Board determined that the Veteran's asthma existed prior to his active military service and was not aggravated therein. Case law has held that a Medical Board's determination is insufficient when not accompanied by an explanation. Horn v. Shinseki, 25 Vet. App. 231 (2012). However, here that determination was accompanied by a Medical Board report of March 12, 1969 which included supporting rationale; Hence, the Medical Board determination is considered highly probative in this case regarding the matter of whether aggravation was or was not shown by clear and unmistakable evidence. The Board also observes that post-service, it was not until 1971, approximately 2 years after service that the Veteran was again treated for asthma (see 1998 statement of Dr. W.S). Evidence of a prolonged period without medical complaint can be considered, along with other factors, as evidence of whether a pre-existing condition was aggravated by military service. See Maxson v. Gober, 230 F. 3d 1330 (Fed. Cir. 2000). The Board has considered the August 2005 medical statement of Dr. J. H. D. in which the doctor indicated that the Veteran had a life-long history of bronchial asthma which had been treated by several physicians. It was noted that symptoms were relatively mild and apparently controlled well with medication. It was noted that on service enlistment, the Veteran gave a medical history of asthma, but it was not considered disqualifying. The doctor indicated that during the course of military service, "with exposure to varying weather patterns, having to perform in the heat, wet weather, and exposure to dust, the barracks environment and incompatible dietary substances, his asthma was severely aggravate." The doctor added that since his discharge, the Veteran had continued to experience significant respiratory difficulty. It was concluded that the Veteran unquestionably had documented bronchial asthma, which by history, was aggravate by military service. The Court has held that VA cannot reject a medical opinion simply because it is based on a history supplied by the Veteran and that the critical question is whether that history was accurate. Kowalski v. Nicholson, 19 Vet. App. 171 (2005); see also Coburn v. Nicholson, 19 Vet. App. 427, 432 (2006) (reliance on a veteran's statement renders a medical report incredible only if the Board rejects the statements of the veteran). Here, the aforementioned private medical opinion of 2005 is of little probative value. Initially, it is clear that it is largely based on an unsubstantiated lay history provided by the Veteran in pursuit of compensation, and not upon any independent review of the Veteran's STRs or clinical history, which would have reflected that the Veteran had essentially only 15 days of service. Moreover, the history provided by the Veteran in 2005 is both remote (provided 35 years after his discharge from service) and unsubstantiated by the record. In this regard, the STRs fail to mention exposure to diet, dust, and or, hot/wet weathers as factors related to the diagnosis of bronchial asthma made in service. As such, there is reason in this case to question the credibility of the lay information and history provided by the Veteran to Dr. J.H.D., and to therefore assign that opinion overall lower probative value than the STRs and VA opinion. See Macarubbo v. Gober, 10 Vet. App. 388 (1997) (holding that the credibility of lay evidence can be affected and even impeached by inconsistent statements, internal inconsistency of statements, inconsistency with other evidence of record, facial implausibility, bad character, interest, bias, self-interest, malingering, desire for monetary gain, and witness demeanor). Additionally, after a full examination and review of the claims file, a VA examiner determined in June 2012, that it was less likely than not that asthma was caused or worsened by service. It was explained that even given factors in service such as cold air and exercise, these are characteristics of asthmatic bronchospasm which do not cause permanent worsening. The examiner clarified that these factors are not toxic agents capable of permanent worsening or damage to the bronchial mucosa. As previously stated, temporary or intermittent flare-ups of the pre-existing disorder during the active military service are not sufficient to be considered aggravation unless the underlying disorder, as contrasted to symptoms, has worsened. Crowe, 7 Vet. App. at 247-48; Hunt, 1 Vet. App. at 296-97. In essence the opinion stands for the conclusion that aggravation of pre-existing asthma in or by service was not shown by clear and unmistakable evidence. The Board also notes that the Veteran's contentions to the effect that when he received multiple shots in 1968 during basic training, asthma immediately emerged from a long period of quiescence since childhood are meritless, lack credibility, and are of no probative value in this case. As an initial matter, the Veteran himself admits that he has no idea what shots were administered during service. Significantly, the STRs include an immunization record which reflects that no shots were administered during service. Moreover, in a March 4, 1969 record, the Veteran reported that he had suffered from asthma and hay fever since childhood, for which he frequently used oral medications; thereby refuting his later statements that asthma had been latent since childhood. Similarly the information regarding occupational asthma as discussed in the Merck Manual is of no probative value in this case. Initially, the Board observes that occupational asthma has never been diagnosed in this case. Moreover, with respect to antibiotics being a potential allergen for asthma, the Veteran himself has indicated that he has no idea whether antibiotics were ever administered to him during service. With respect to medical treatise evidence discussed above, the Court has held that a medical article or treatise "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998) and Wallin v. West, 11 Vet. App. 509 (1998). Here, the medical information does not specifically pertain to the Veteran's case, it is not accompanied by any supporting medical opinion pertinent to his individual case, and the clinical evidence and medical opinions on record relating to the Veteran's specific case are unfavorable. Accordingly, the medical treatise evidence is of no probative value in this case. The Board has considered the Veteran's arguments in support of his claim. The Board acknowledges that a person may be competent, even as a layperson, to attest to factual matters of which he or she has first-hand knowledge, e.g., an injury during his active military service. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that lay evidence is one type of evidence that must be considered, and that competent lay evidence can be sufficient in and of itself. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006). In Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009), and in Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), the Federal Circuit determined that lay evidence can be competent and sufficient to establish a diagnosis of a disorder when: (1) a layperson is competent to identify the medical disorder (noting that sometimes the layperson will be competent to identify the disorder where the disorder is simple, for example a broken leg, and sometimes not, for example, a form of cancer), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. The relevance of lay evidence is not limited to the third situation, but extends to the first two as well. Whether lay evidence is competent and sufficient in a particular case is a fact issue. Id. In this case, the Veteran is competent to relate the respiratory symptomatology he experienced prior to, during and subsequent to his period of military service. As a layman, however, he does not possesses the medical expertise to provide a competent medical opinion regarding the question as to whether the respiratory symptoms which existed prior to service, and were reported during service, represented a permanent increase in severity of the preexisting condition or only a temporary, acute exacerbation of this condition, the conclusion reached by both the Medical Board in March 1969 and by a VA examiner in 2012. Accordingly, the Board finds that the most probative evidence in this case are the STRs themselves, and the opinion provided by the VA examiner, who based his conclusion on his medical knowledge, a review of the Veteran's STRs and a physical examination of the Veteran in 2012. The above information constitutes clear and unmistakable evidence that the Veteran's asthma existed prior to service and was not aggravated by active military service. Thus, the Veteran's claim of entitlement to service connection for asthma is not warranted and the appeal is denied. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). B. Pes Planus The STRs include a report of physical examination conducted on February 27, 1969, at which time listed defects noted included pes planus. Throughout the remainder of the Veteran's service from which he was discharged on March 21, 1969, the STRs are negative for complains, clinical findings, treatment or a diagnosis of pes planus. In November 2009, the Veteran filed a service connection claim for pes planus and requested an examination to be conducted by a board certified podiatrist. VA records include an entry dated in January 2002 indicating that the Veteran was seen for complaints of decreased sensation in the feet associated with diabetes mellitus Type II. The entry also mentioned that a foot deformity described as pes planus was shown. A January 2003 record notes pes planus with some diffuse callosities. Also on file is a June 2005 radiology report issued in conjunction with the Veteran's complaints of forefoot pain and puffiness. Impressions of left-sided calcaneal spur and soft tissue swelling without underlying bony abnormalities was made. It was noted that the Veteran had undergone a previous surgery along the first MJP joint. In a December 2009 statement, the Veteran indicated that he had experienced foot problems since service. In December 2010, the Veteran issued a statement asserting that pes planus was not a congenital condition, and that it had not been noted on service enlistment. In a July 2011, statement the Veteran asserted that the April 2010 rating action contained clear and unmistakable error and that the law did not require objective proof of aggravation under 38 C.F.R. § 3.306. A VA examination of the feet was conducted in June 2012, at which time flat foot was diagnosed. Following a review of the claims folder, the VA examiner opined that it was less likely than not that military service affected the Veteran's feet more than normal aging. It was observed that there were no records documenting complaints of foot pain until the 1990's, and that the Veteran's morbid obesity would accentuate any lower extremity problems such as flat feet or other causes of foot pain. Analysis In this case, on a February 27, 1969 addendum to a February 1968 Report of Medical Examination on the Veteran's entry into service, the Veteran was found to have pes planus. Accordingly, the record shows that the Veteran entered service with pre-existing pes planus and the presumption of soundness is rebutted since it was noted for entrance purposes. Having determined that the Veteran entered service with pre-existing pes planus, the next step involves examining whether there has been any measurable worsening of the disability during service and whether this worsening constitutes an increase in disability. Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). If there is an increase in severity, there is a rebuttable presumption of aggravation. 38 U.S.C.A. § 1153. Here, the Board finds that there was no increase in severity during service. The Veteran's STRs reveal no complaints of, or treatment for pes planus, after pes planus was initially identified on enlistment in February 27, 1969. Thereafter, it was not until decades later that the Veteran's had any foot complaints. or that pes planus was documented in a medical record (2002 and 2003). Moreover, in June 2012, a medical opinion was obtained to address the issue of whether the Veteran's pes planus was aggravated beyond its normal progression during service. Following a review of the claims folder, the VA examiner opined that it was less likely than not that military service affected the Veteran's feet more than normal aging. It was observed that there were no records documenting complaints of foot pain until the 1990's, and that the Veteran's morbid obesity would accentuate any lower extremity problems such as flat feet or other causes of foot pain. In essence, the examiner found that the Veteran's pre-existing pes planus was likely not aggravated by military service. The post-service medical record also does not support a measurable worsening of the condition during service. The Veteran separated from service in March 1969 and the earliest post-service medical evidence of record pertaining to pes planus is shown in 2002. Significantly, the Veteran did not even file a service connection claim for pes planus until 2008, almost 40 years after discharge from service. The above information, taken in totality, constitutes probative and persuasive evidence that the Veteran's pre-existing pes planus was not aggravated by service. There is no reliable evidence to show a worsening of the condition as the result of service; the only reliable evidence in this case is to the contrary. As such, the Board concludes that there was no increase in severity and no aggravation. The Board must also consider the Veteran's lay statements that his pes planus was worsened by service and chronic since that time. While the Veteran is competent to testify as to his observation of worsening foot symptoms, the internal cause of both the claimed chronic symptoms and worsening of symptoms would appear to be the type of medical matter as to which the courts have held lay testimony is not competent. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (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). Compare Jandreau, 492 F.3d at 1376 (lay witness capable of diagnosing dislocated shoulder); Barr, 21 Vet. App. at 308-309 (lay testimony is competent to establish the presence of varicose veins); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer."). In any event, even if the Veteran were competent to opine as to the etiology of his pes planus, the specific and reasoned opinion of the trained professional finding a lack of aggravation of a pre-existing disorder, outweighs the Veteran's general lay assertion of aggravation. It is further observed that the Veteran's contentions regarding aggravation of his pre-existing foot condition have been rather vague and non-specific. For the foregoing reasons, the evidence establishes that pes planus was noted at entrance, that there was no increase in severity during service, and that the presumption of aggravation does not attach. Beverly v. Brown, 9 Vet. App. 402 (1996). Given the preexisting disease and lack of in-service aggravation, entitlement to service connection for bilateral pes planus on an aggravation basis is not warranted. Consequently, the benefit of the doubt doctrine is not for application, and the claim for entitlement to service connection for pes planus must be denied. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER service connection for asthma, to include bronchial asthma and bronchitis, is denied. Service connection for bilateral pes planus is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs