Citation Nr: 1323787 Decision Date: 07/25/13 Archive Date: 08/06/13 DOCKET NO. 06-30 229 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Phoenix, Arizona THE ISSUES 1. Entitlement to service connection for a left ankle disability. 2. Entitlement to service connection for a bilateral foot disability. 3. Entitlement to service connection for ischemic heart disease with angina and congestive heart failure (a "heart disability"), claimed as secondary to diabetes mellitus. 4. Entitlement to service connection for a kidney disability, claimed as secondary to diabetes mellitus. 5. Entitlement to a rating in excess of 10 percent for peripheral neuropathy of the right upper extremity. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD D. Schechner, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from August 1959 to June 1981. These matters are before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Phoenix, Arizona RO issued in July 2002 (which in pertinent part denied service connection for ischemic heart disease and kidney disease, and granted service connection for peripheral neuropathy of the right upper extremity, rated 10 percent, effective July 9, 2001) and in April 2003 (which in pertinent part denied service connection for a left ankle disability and a bilateral foot disability). In March 2011, the Board remanded these matters for additional development. FINDINGS OF FACT 1. A chronic left ankle disability was not manifested in service; arthritis of the left ankle was not manifested in the first year following the Veteran's discharge from active duty; and a left ankle disability is not shown to be related to the Veteran's service. 2. A chronic foot disability was not manifested in service; arthritis of a foot was not manifested in the first year following the Veteran's discharge from active duty; and a disability of either foot is not shown to be related to the Veteran's service. 3. The Veteran is not shown to have a chronic heart disability entity/ischemic heart disease.. 4. The Veteran is not shown to have a chronic kidney disability. 5. The Veteran's peripheral neuropathy of the right upper extremity is manifested by impairment no greater than mild incomplete paralysis of the median nerve; moderate incomplete paralysis of the median nerve is not shown. CONCLUSIONS OF LAW 1. Service connection for a left ankle disability is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 2. Service connection for a bilateral foot disability is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2012). 3. Service connection for a heart disability/ischemic heart disease is not warranted. 38 U.S.C.A. §§ 1110, 1112, 1113, 1116, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 4. Service connection for a kidney disability is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.310 (2012). 5. A rating in excess of 10 percent for peripheral neuropathy of the right upper extremity is not warranted. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.21, 4.124a, Diagnostic Code (Code) 8515 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). VCAA notice requirements apply to all five elements of a service connection claim: 1) veteran status; 2) existence of a disability; 3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473, 484-86 (2006), aff'd, 483 F.3d 1311 (Fed. Cir. 2007). VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction decision on a claim. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The Veteran was advised of VA's duties to notify and assist in the development of the claims prior to their initial adjudication. August 2001, February 2003, and June 2004 letters explained the evidence necessary to substantiate the claims, the evidence VA was responsible for providing, and the evidence he was responsible for providing. A March 2006 letter informed him of disability rating and effective date criteria. He has had ample opportunity to respond/supplement the record and has not alleged that notice in these matters was less than adequate. As the rating decision on appeal granted service connection for peripheral neuropathy of the right upper extremity and assigned a disability rating and effective date for the award, statutory notice had served its purpose, and its application was no longer required. See Dingess/Hartman, supra. A June 2004 statement of the case (SOC) provided notice on the "downstream" issue of entitlement to an increased initial rating, and a May 2012 supplemental SOC readjudicated the matter after the appellant and his representative responded and further development was completed. 38 U.S.C.A. § 7105. The Veteran's service treatment records (STRs) are associated with his claims file, and pertinent postservice treatment records have been secured. Social Security Administration (SSA) records have been secured. The RO arranged for VA examinations in November 2001, June 2002, February 2003, September 2003, February 2004, March 2006, July 2011, August 2011, and March 2012. As will be discussed in greater detail below, the Board finds these examinations (cumulatively) to be adequate, as they included a thorough review of the Veteran's medical history, physical examinations citing all pertinent findings, and medical opinions with adequate supporting rationale. See Barr v. Nicholson, 21 Vet. App. 303 (2007). The Veteran has not identified any pertinent evidence that remains outstanding. VA's duty to assist is met. Legal Criteria, Factual Background, and Analysis Initially, the Board notes that it has reviewed all of the evidence in the Veteran's claims file and in Virtual VA (VA's electronic data storage system) with an emphasis on the evidence relevant to this appeal. 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). 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. The Board also notes at the outset that the Veteran was awarded a Combat Infantryman Badge and is entitled to the relaxed evidentiary standards afforded under 38 U.S.C.A. § 1154(b). However, it is not alleged that the disabilities on appeal are combat-related. Where dispositive question is one of a diagnosis of a current disability or a nexus between a current disability and remote service/event(s) therein, § 1154(b) has no applicability. Service connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). In order to establish service connection for the claimed disorder, there must be (1) evidence of a current disability; (2) evidence of incurrence or aggravation of a disease or injury in service; and (3) evidence of a causal connection between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Disorders diagnosed after discharge may still be service connected if all the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Certain chronic disabilities (including arthritis and cardiovascular-renal disease) may be service-connected on a presumptive basis if manifested in a specified period of time following a veteran's discharge from active duty (one year for arthritis and cardiovascular disease). 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (e.g., a broken leg), (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. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is needed where the determinative question is one requiring medical knowledge. Id. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. It may also mean statements conveying sound medical principles found in medical treatises, and may include statements in authoritative writings, such as medical and scientific articles and research reports. 38 C.F.R. § 3.159(a)(1). Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a layperson. 38 C.F.R. § 3.159(a)(2). Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a) (as in effect before and after October 10, 2006). Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease, will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. The rating activity will determine the baseline and current levels of severity under the Schedule for Rating Disabilities and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. 38 C.F.R. § 3.310 (b). Left ankle disability The Veteran contends that he has a left ankle disability that was incurred in service. His STRs show that he twisted his right ankle in June 1981 [a right ankle disability is service connected]. The STRs are silent for any complaints, findings, treatment, or diagnosis regarding the left ankle. On April 1981 service retirement examination, the lower extremities were abnormal on clinical evaluation due to bilateral knee surgery scars; no other abnormalities were noted. A claim for VA compensation benefits received in June 1981 (prior to the Veteran's retirement) reflects that the only disabilities for which compensation was sought involved both knees and the right shoulder. The earliest documented postservice complaint pertaining to the Veteran's left ankle was on September 2001 VA treatment, when he reported pain in his ankles. On June 2002 VA examination, the Veteran reported noticing that his ankles tended to swell up; he had been taking water pills for the previous six to seven years. On February 2003 VA examination, the Veteran reported ongoing daily bilateral ankle stiffness. He reported that the left ankle stiffness occurred mostly during the waking hours of the day and progressively mitigated after mobility as the day progressed. He also reported a dull ache which exacerbated on prolonged periods of ambulation and standing. He denied any blunt trauma to his lower extremities or any surgical procedures. He denied requiring corrective shoe gear, ankle braces, or assistive ambulatory devices. He reported he recently had osteoarthritis of multiple joints diagnosed. Following a physical examination, the assessments included left ankle discomfort with multiple etiologies, namely already-documented osteoarthritis, obese body habitus, concurrent bilateral pes planus, improper use of shoe wear with limited support, and heel spurs and plantar spurs. Despite his physical discomfort, the Veteran had a normal gait and normal range of motion of the left ankle. On February 2004 VA examination, the Veteran reported that he twisted his ankle and fell while in training in 1962, with additional injuries to the left ankle in 1966 and in May 1981. He reported that he still had left ankle symptoms at the time of his separation from service. He reported occasional soreness of the ankle that varied in intensity. Following a physical examination, the diagnoses included left ankle mild degenerative joint disease. The examiner opined that it was less likely as not that systemic degenerative disease of multiple joints began in military service as there was no evidence of systemic degenerative disease; however, the examiner opined that the left ankle disability "at least as likely as not is related to military service". The examiner stated that "there is no such thing as 'times and circumstance' of a veteran's military career and therefore it is less likely as not that the current disease of the left ankle ... developed as a result of this." In March 2011, the Board noted that the rating decision on appeal misrepresented the February 2004 VA examiner's opinion (indicating that it is against the Veteran's claim when, in fact, it is internally inconsistent, as it both expresses support for the claim and provides an opinion against the claim). The Board found that the February 2004 examiner's opinion provides insufficient explanation of rationale to constitute adequately probative evidence. To the extent that it supports the claim of service connection, it does not identify the disease or injury in service to which the claimed disability may be related (as the Veteran's STRs and service separation examination report are silent for left ankle disability). The Board remanded the matter for a new examination to secure an adequate nexus opinion. On July 2011 VA examination, the Veteran reported pain in both ankles; he reported having multiple bilateral ankle sprains in service which were treated with icing and rest, as well as a history of jumping off helicopters and towers during service. He reported being treated for bilateral lateral ankle pain with injections in the VA podiatry clinic. He reported symptoms of giving way, instability, pain, stiffness, weakness, incoordination, and decreased speed of joint motion, with several episodes per year of dislocation or subluxation. There were no constitutional symptoms, or incapacitating episodes, of arthritis. On physical examination, there was pain on palpation to the ATF and CF ligaments as well as to the medial gutter and deltoid ligament. There was pain on palpation to the Achilles tendon without thickening or nodules, and pain on palpation to the peroneus brevis from insertion on styloid process to posterior to the lateral malleolus. X-rays of the left ankle demonstrated an intact appearing ankle joint. The diagnoses included residuals of left ankle sprain, Achilles tendonitis, and peroneal tendonitis. The examiner opined after reviewing the claims file that the Veteran's current left ankle condition and peroneal tendonitis is consistent with residuals from a previous left inversion sprain, yet noted that there is no documentation in the claims file to support an inversion sprain to the left ankle occurred in service. The examiner added that if a left ankle sprain did occur while on active duty, then the Veteran's current left ankle condition and peroneal tendonitis would be as least as likely as not (50/50 probability) caused by or a result of the left ankle inversion sprain. The examiner stated that it could not be determined without resort to mere speculation whether the Veteran's Achilles tendonitis was a result of, or related to, his service, as there is no documentation of specific foot pain during service in the claims file; the examiner opined that the Achilles tendonitis is less likely as not (less than 50/50 probability) caused by or a result of any ankle inversion sprain that occurred in service. The Veteran has also submitted VA treatment records through January 2012 showing findings similar to those on the VA examinations outlined above. SSA records reflect that the Veteran receives disability benefits for disabilities of his back, knees, shoulders, and wrists. His May 1994 application for SSA disability benefits, as well as an August 1994 SSA examination for benefits, made no mention of the left ankle. The Board finds that the July 2011 VA examiner's opinion is entitled to great probative weight, as it reflects a complete review of the Veteran's complete medical history and statements included in the claims file and includes a detailed explanation of rationale. A left ankle disability was not diagnosed in service or postservice until approximately 2003, or 22 years after the Veteran's retirement from active duty. While he has reported (including on February 2004 VA examination) that he has had continuous left ankle problems since an injury in service, and in medical records since February 2004 he has attributed his current left ankle complaints to such injury, those accounts have been inconsistent and are self-serving. Furthermore, where contemporaneous records would be expected to provide support for the accounts, they do not. Consequently, the Board finds his reports of left ankle symptoms existing ever since an injury in service to not be credible. The Board finds significant that when the Veteran retiring from service (and filed his first claim seeking VA compensation benefits), the only disabilities for which compensation was sought involved his knees and his right shoulder. Logically, if a chronic left ankle problem was manifest at the time, he would have included such among his claims. Additionally, the Veteran has not reported (upon VA requests to identify any such treatment) seeking left ankle treatment postservice prior to 2001 (when he first reported pain in his ankles), as would be expected with a significant longstanding left ankle problem. Consequently, service connection for a left ankle disability on the basis that such disability became manifest in service, and persisted, is not warranted. Inasmuch as there is no evidence that left ankle arthritis was manifested in the first year following the Veteran's separation from active duty, presumptive service connection for such disability (as a chronic disease under 38 U.S.C.A. §§ 1112, 1137) likewise is not warranted. The Board finds further that the preponderance of the evidence is against the Veteran's claim seeking service connection for a left ankle disability. The Veteran contends that he suffered sprains to both ankles in service, yet it is only shown in the STRs that he sought treatment for a right ankle sprain; the STRs are silent regarding the left ankle. The fact that the Veteran sought VA compensation benefits at the time of his retirement for other disabilities yet made no mention of any disability of his left ankle weighs against a finding that there was chronic left ankle pathology present in service The only medical evidence that directly addresses the matter of a nexus between the Veteran's current left ankle disability and his service/injury therein, with adequate supporting rationale, is the report of the July 2011 VA examination, when the examiner opined that the Veteran's left ankle complaints are unrelated to his service or any injury therein as no such injury is shown. The physician noted the history of the claimed and diagnosed disabilities and thoroughly explained the rationale for the opinion. The Board finds this evidence highly probative in the matter at hand (as the examiner is a medical professional qualified to provide it and supports it with explanation of rationale and citation to supporting factual data). Because there is no competent (medical opinion/treatise) evidence to the contrary, the Board finds the July 2011 VA examiner's opinion to be persuasive. In the absence of credible evidence of continuity of symptoms, the Veteran's own assertions that there is a nexus between his current left ankle disability and an injury in service are not competent evidence. The etiology of an insidious process such as arthritis is a matter beyond the capability of lay observation, but is a complex medical question that requires medical knowledge/training. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Veteran is a layperson, and lacks the training/expertise to offer a probative opinion in the matter; he does not cite to supporting medical opinion or treatise evidence, and does not provide any adequate explanation of rationale for his theory or entitlement (other than the allegation of continuity of symptoms, which the Board has found not credible). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for a left ankle disability. Accordingly, the appeal in the matter must be denied. Bilateral foot disability The Veteran contends that he has a chronic bilateral foot disability that was incurred in service. His STRs are silent for any complaints, findings, treatment, or diagnosis regarding the feet. On April 1981 service retirement examination, the feet were normal on clinical evaluation. A claim for VA compensation benefits received in June 1981 (prior to the Veteran's retirement) reflects that the only disabilities for which compensation was sought were of the knees and the right shoulder. The earliest documented postservice complaint pertaining to the Veteran's bilateral feet was on April 1992 VA examination, when he reported tinea pedis involving both feet which was being treated; the diagnoses included bilateral tinea pedis. Subsequent treatment records also include assessments of tinea pedis. [The Board notes that the Veteran is already service connected for tinea pedis of both feet, and the rating for such disability is not on appeal at this time.] On February 2001 VA treatment, the Veteran was noted to have a leg length discrepancy (LLD) of the right foot and was fitted with orthotics. On July 2001 VA treatment, he complained of a painful right foot callus. It was noted that he had received orthotics for LLD, but he had yet to begin wearing them. He reported that he walked barefoot frequently, and recently began experiencing pain on the plantar-lateral aspect of the right foot. The impressions included LLD right greater than left, and heloma durum (HD) of the right foot. On June 2002 VA examination, the Veteran reported a history of pain radiating down from the hips into the feet, which came and went and fluctuated in varying degrees - at the time of examination it was relatively mild. On February 2003 VA examination, the Veteran reported having some podiatry evaluations for problems with ingrown toenails and tinea pedis changes; he reported taking antifungal agents. He denied any blunt trauma to his lower extremities or any surgical procedures. He denied requiring corrective shoe gear, ankle braces, or assistive ambulatory devices. He reported recently receiving a diagnosis of multiple joint osteoarthritis. Following a physical examination, the assessments included left ankle discomfort with multiple etiologies, namely already-documented osteoarthritis, obese body habitus, concurrent bilateral pes planus, improper use of shoe wear with limited support, and heel spurs and plantar spurs. Despite his physical discomfort, the Veteran had a normal gait. June 2000 X-rays of the feet were reported to show evidence of mild degenerative joint disease and bilateral plantar and posterior calcaneal spurs. On February 2004 VA examination, the Veteran reported that a Jeep ran over his toes while he was in service. He reported having burning in his heel areas in service, left greater than right, with no injuries to either hindfoot and no surgery. He denied having flatfoot prior to service. He reported having almost daily soreness of the feet and the heel areas. Following a physical examination, the diagnoses included bilateral minimal pes planus and plantar and calcaneal spurs. The examiner stated that "there is no such thing as 'times and circumstance' of a veteran's military career and therefore it is less likely as not that the current disease of the ... feet developed as a result of this." However, the examiner concluded that the conditions of both heels [plantar and calcaneal spurs] as likely as not are related to military service. The examiner opined that the minimal pes planus of both feet was also as likely as not related to military service. In March 2011, the Board noted that the rating decision on appeal misrepresented the February 2004 VA examiner's opinion (indicating that it is against the Veteran's claim when, in fact, it is internally inconsistent, as it both expresses support for the claim and provides an opinion against the claim). The Board found that the February 2004 examiner's opinion included insufficient explanation of rationale to constitute adequately probative evidence; to the extent that it supported the claim of service connection, it did not identify the disease or injury in service to which the claimed disability may be related (as the Veteran's STRs and service separation examination report are silent for bilateral foot disabilities). The Board remanded the matter for a new examination to secure an adequate nexus opinion. On July 2011 VA examination, the Veteran complained of pain to the plantar arch, lateral foot, and midfoot, as well as tingling/burning to the toes and feet that he related to his diabetes. He reported he had no history of foot related hospitalization or surgery, foot trauma, or neoplasm. He reported he used diabetic corrective shoes to treat his foot pain. On physical examination, there was swelling and tenderness of both feet with pain on palpation to the medial band of the left plantar fascia and to the peroneous brevis insertion bilaterally. X-rays of the right foot showed plantar and posterior calcaneal spurs, an old periosteal reaction in the fourth metatarsal bone, and mild degenerative changes with minimal spur formation of the first and second metatarsal phalangeal joints; X-rays of the left foot showed prominent posterior and tiny plantar calcaneal spurs, old periosteal reactive changes in the second, third, and fourth metatarsal bones, and mild degenerative changes with minimal spur formation of the first metatarsophalangeal joint. The diagnoses included right plantar fasciitis. The examiner stated that it could not be resolved without resort to mere speculation whether the right plantar fasciitis was a result of or related to the Veteran's service. The examiner noted that there is no documentation of specific foot pain in service in the claims file. The Veteran has also submitted VA treatment records through January 2012 showing findings similar to those on the VA examinations outlined above. SSA records reflect that the Veteran receives disability benefits for disabilities of his back, knees, shoulders, and wrists. His May 1994 application for SSA disability benefits, as well as an August 1994 SSA examination report do not mention the feet. The Board finds that the July 2011 VA examiner's opinion is entitled to great probative weight, as it reflects a complete review of the Veteran's complete medical history and statements included in the claims file and includes a detailed explanation of rationale. A foot disability was not diagnosed in service or postservice until approximately 2001, some 20 years after the Veteran's retirement from active duty. While he has reported (including on February 2004 VA examination) that he has had continuous bilateral foot problems since an injury in service, and in medical records since February 2004 has attributed his current bilateral foot complaints to such injury, his accounts have been inconsistent and are self-serving. Furthermore, where contemporaneous records would be expected to provide support for the accounts, they do not. Consequently, the Board finds his reports of bilateral foot symptoms existing ever since an injury in service to not be credible. Furthermore, the Board also finds significant that when the Veteran retiring from service (and first filed a claim seeking VA compensation benefits), the only disabilities for which compensation was sought were of his knees and right shoulder. Logically, if a bilateral foot problem was manifest at the time, he would have included such disability in his claims. Additionally, the Veteran has not reported (upon VA requests to identify any such treatment) seeking foot treatment postservice prior to 2001, as would be expected with a significant longstanding bilateral foot problem. Consequently, service connection for a bilateral foot disability on the basis that such disability became manifest in service, and persisted, is not warranted. Inasmuch as there is no evidence that bilateral foot arthritis was manifested in the first year following the Veteran's retirement from active duty, presumptive service connection for such disability (as a chronic disease under 38 U.S.C.A. §§ 1112, 1137) likewise is not warranted. The Board finds further that the preponderance of the evidence is against the Veteran's claim seeking service connection for a bilateral foot disability. There is no evidence that he sustained a foot injury in service that may have resulted in any chronic foot pathology/disability. The fact that on retirement he VA compensation benefits for other disabilities but made no mention of a foot disability weighs against a finding that there was chronic foot pathology present in service The only medical evidence that directly addresses the matter of a nexus between the Veteran's current bilateral foot disability and his service/injury therein, with adequate supporting rationale, is the report of the July 2011 VA examination, when the examiner opined that the Veteran's bilateral foot complaints are unrelated to his service or any injury therein. The physician noted the history of the claimed and diagnosed disabilities and thoroughly explained the rationale for the opinion. The Board finds this evidence highly probative in the matter at hand (as the examiner is a medical professional qualified to provide it and supports it with explanation of rationale and citation to supporting factual data). Because there is no competent (medical opinion/treatise) evidence to the contrary, the Board finds the July 2011 VA examiner's opinion to be persuasive. In the absence of credible evidence of continuity of symptoms, the Veteran's own assertions that there is a nexus between his current bilateral foot disability and an injury in service are not competent evidence. The etiology of an insidious process such as arthritis is a matter beyond the capability of lay observation, but is a complex medical question that requires medical knowledge/training. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). The Veteran is a layperson, and lacks the training/expertise to offer a probative opinion in the matter; he does not cite to supporting medical opinion or treatise evidence, and does not provide any adequate explanation of rationale for his theory or entitlement (other than the allegation of continuity of symptoms, which the Board has found not credible). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for a bilateral foot disability. Accordingly, the appeal in the matter must be denied. Heart disability If a veteran, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam Era (from January 9, 1962 to May 7, 1975), and has one of the specified diseases associated with exposure to certain herbicide agents [to include Agent Orange], that disease shall be considered to have been incurred in or aggravated by such service, notwithstanding that there is no record or evidence of such disease during the period of such service. See 38 U.S.C.A. § 1116. VA has amended the regulations concerning Agent Orange to establish presumptive service connection based on herbicide exposure for ischemic heart disease. The proposed rule clarifies that ischemic heart disease includes, but is not limited to, "acute, subacute, and old myocardial infarction; atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina". See 75 Fed. Reg. 14,391, 14,393 (Mar. 25, 2010). The record reflects the Veteran served in the Republic of Vietnam . He is presumed to have been exposed to herbicides in service. The Veteran's theory of entitlement to this benefit has essentially been one of secondary service connection. Service connection has been established for posttraumatic stress disorder (PTSD), left knee arthroplasty, residuals of a right shoulder injury with traumatic degenerative arthritis, residuals of a right knee injury with traumatic arthritis, cervical spine syndrome, traumatic degenerative joint disease of the left shoulder, bilateral tinea pedis, peripheral neuropathy of both upper extremities and of both lower extremities, seborrheic dermatitis of the face and scalp, right ankle inversion sprain, erectile dysfunction, and diabetes mellitus. The Veteran seeks service connection for a heart disability on the basis that it was caused or aggravated by his service-connected diabetes mellitus. The Veteran's STRs include a complaint of self-diagnosed "heart trouble" in October 1963; the impression was hyperventilation attacks. On April 1981 service retirement examination, the heart was normal on clinical evaluation. Postservice medical records include an October 1987 chest X-ray which showed borderline cardiomegaly, contributed to by less than optimal inspiration, a prominent fat pad, and a somewhat narrow AP chest diameter. A June 1994 chest X-ray showed no acute or chronic cardiopulmonary disease. On August 1994 SSA examination for disability benefits, the Veteran reported a 25 year history of sharp substernal chest pain with associated ringing in the ears, shortness of breath, and diaphoresis. On physical examination, the heart showed regular rhythm with no murmurs or gallops. The impressions included chest pain, probably non-cardiac in origin. On November 2001 VA diabetes examination, the Veteran reported that he was taking medication for heart disease; he reported having chest pain in service which went undiagnosed, and that he developed chest pain four years earlier due to angina which was now relieved with nitroglycerin. The impressions included ischemic heart disease with angina and congestive heart failure, despite a lack of abnormal findings on physical examination. A chest X-ray showed no active chest disease. On June 2002 VA examination, the Veteran reported having chest pains for a number of years, beginning in the sterna region and extending to the pectoral region and often into the left arm and forearm. He occasionally took nitroglycerin. On hospitalization in 1997, there was no evidence that the pain was of cardiac origin, and the Veteran reported that a 1998 private cardiologic consult revealed that "everything was fine". The examiner noted that a 1997 MUGA scan showed no evidence of heart failure, a November 2001 chest X-ray showed normal heart size, and a December 2001 treadmill test showed no evidence of heart disease. The examiner opined that the Veteran had no heart conditions, no evidence of ischemic heart disease, and no evidence of enlarged heart or heart failure. On September 2003 VA general medical examination, the examiner noted that the Veteran had never been determined to have any coronary artery disease although he was hospitalized with atypical chest pains in 1997. The examiner also noted a December 2001 stress test which showed no evidence of ischemia, opining that the Veteran had not been determined to have any coronary disease or other heart disease. On March 2006 VA examination, the examiner found no documented coronary event but noted there were indeed risk factors for heart disease such as lipidemia and obesity as well as diabetes mellitus. Following a physical examination, the examiner found no present findings to support a diagnosis of heart disease. The examiner opined that coronary artery disease was less likely than likely present. On August 2011 VA heart disease examination, the examiner opined that the Veteran does not have ischemic heart disease. The examiner explained that, based on a review of the claims file, the Veteran has no documented evidence of ischemic heart disease, to include myocardial infarct, stent intervention, heart surgery, and cardiac catheterization. The examiner noted that an April 2010 EKG test was normal. The threshold requirement here (as in any claim seeking service connection) is that there must be competent evidence that the Veteran has (or during the pendency of the claim has had) the disability for which service connection is sought, i.e., a heart disability. See 38 U.S.C.A. §§ 1110, 1131. As the record does not include any such evidence, there is no valid claim of service connection for heart disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for heart disability. Accordingly, it must be denied. In denying this claim, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claims, the doctrine is not for application. The Veteran is advised that evidence that he in fact does have ischemic heart disease would be a basis for reopening this claim. Kidney disease The Veteran asserts that he takes medication for a kidney disability. The theory of entitlement to the benefit sought is essentially one of secondary service connection. Service connection has been established for PTSD, left knee arthroplasty, residuals of a right shoulder injury with traumatic degenerative arthritis, residuals of a right knee injury with traumatic arthritis, cervical spine syndrome, traumatic degenerative joint disease of the left shoulder, bilateral tinea pedis, peripheral neuropathy of both upper extremities and of both lower extremities, seborrheic dermatitis of the face and scalp, right ankle inversion sprain, and erectile dysfunction, as well as diabetes mellitus. The Veteran seeks service connection for a kidney disability on the basis that it was caused or aggravated by his service-connected diabetes mellitus. The Veteran's STRs are silent for any complaints, findings, treatment, or diagnosis regarding the kidneys. On April 1981 service retirement examination, the genitourinary system was normal on clinical evaluation. In the Veteran's postservice medical records, a May 1987 ultrasound of the abdomen (performed due to complaints of right upper quadrant pain) showed the right kidney to appear normal; there were no acute changes involving the right upper quadrant. A July 1987 ultrasound of the biliary tract showed the right kidney to appear unobstructive. On November 2001 VA diabetes examination, the Veteran reported that he was taking medication for kidney disease. There were no findings or diagnosis regarding the kidneys. On June 2002 VA examination, the examiner noted that the records did not indicate any renal disease. On November 2001 blood studies, the creatinine was normal, and the urine was negative for protein and showed no elevated microalbumin. The examiner opined that the Veteran had no kidney conditions and had normal urine studies. On September 2003 VA general medical examination, the examiner noted that the Veteran had no history of renal disease and his creatinine (tested just within the previous two weeks) was normal. On March 2012 VA examination, the examiner opined that the Veteran did not now have, nor has he ever been diagnosed with, a kidney condition. There was no evidence of kidney dysfunction. There was no history of recurrent symptomatic urinary tract or kidney infections. The examiner noted that the claims file as well as updated records of VA treatment had been reviewed: renal function tests were normal; in January 2011, a serum creatinine was 1.22 mg/dl; a December 2011 microalbumin was 0.4 mg/dl; and December 2011 urinalysis did not show any proteinuria. The threshold requirement here (as in any claim seeking service connection) is that there must be competent evidence that the Veteran has (or during the pendency of the claim has had) the disability for which service connection is sought, i.e., a kidney disability. See 38 U.S.C.A. §§ 1110, 1131. The record does not include any such evidence. Notably, while the Veteran on several occasions has reported he has received a diagnosis of (and was receiving medical treatment for) a kidney disease, his voluminous treatment records associated with the record do not show such diagnosis or treatment. In fact, all evaluations and diagnostic studies for kidney disease have been normal. Significantly, the Veteran has never identified (despite being requested to do so) a physician who diagnosed kidney disease or who provides ongoing treatment. Accordingly, there is no valid claim of service connection for kidney disability. Brammer v. Derwinski, 3 Vet. App. 223 (1992). In light of the foregoing, the Board concludes that the preponderance of the evidence is against the Veteran's claim of service connection for kidney disability. Accordingly, it must be denied. In denying this claim, the Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claims, the doctrine is not for application. Increased rating for peripheral neuropathy of the right upper extremity Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. With the initial rating assigned following a grant of service connection, separate (staged) ratings may be assigned for separate periods of time, based on the facts found. Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt as to the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3. Peripheral neuropathy of the upper extremities is rated under Code 8515. A 10 percent rating is warranted when there is mild incomplete paralysis of the median nerve. A 20 percent rating is warranted when there is moderate incomplete paralysis of the median nerve of the nondominant arm; a 30 percent rating is warranted when there is moderate incomplete paralysis of the median nerve of the dominant arm. A 40 percent rating is warranted when there is severe incomplete paralysis of the median nerve of the nondominant arm; a 50 percent rating is warranted when there is severe incomplete paralysis of the dominant arm. A 60 percent rating is warranted when there is complete paralysis of the median nerve of the nondominant arm; a 70 percent rating is warranted when there is complete paralysis of the dominant arm. 38 C.F.R. § 4.124a. On October 2000 VA treatment, the Veteran was noted to have bilateral sensory neuropathy and moderate carpal tunnel syndrome, with symptoms worse on the left than the right, with some relief with braces. He reported numbness in all fingers, often relieved with manipulation of the shoulder. The assessments included moderate carpal tunnel syndrome and sensory neuropathy. He was fitted with bilateral wrist splints for carpal tunnel syndrome. On September 2001 VA treatment, the Veteran complained that his hands were painful, swollen, and stiff. On November 2001 VA diabetes examination, the Veteran reported numbness of the fingers. On physical examination, there was a hyperesthesia to pinprick but not to light-touch in a glove distribution. The impressions included type 2 diabetes mellitus with mild sensory peripheral neuropathy. On June 2002 VA examination, the Veteran reported burning and sharp pain associated with a squeezing feeling over the muscles of his right arm. He reported having a loss of feeling in his hands that would awaken him at night or would occur while driving a car. He had not had any hand surgery. On physical examination, motor examination showed 5/5 strength and good bulk and normal tone and normal muscle groups to the upper extremities. There was no drift fasciculation or atrophy. Reflexes were trace in the upper extremities. Sensory examination to light touch, vibration and position was normal. The examiner opined that the Veteran did not clearly demonstrate any neurologic findings on examination. The impressions following electromyography testing included essentially normal EMG with no denervation and minimal polyneuropathy, diabetic, with superimposed carpal tunnel syndromes. Based on that examination, the July 2002 rating decision on appeal granted the Veteran service connection for peripheral neuropathy of the right upper extremity secondary to diabetes mellitus, rated 10 percent, effective July 9, 2001. The Veteran contends that his disability merits a higher rating. On September 2003 VA examination, the examiner noted that the Veteran's peripheral neuropathy of the upper extremities was "very tentative" as a complication of his diabetes. The Veteran reported no current numbness or loss of feeling, rather just an intermittent feeling of tingling and numbness in the hand which lasted a minute at the longest but could occur several times a day. He reported that it frequently woke him up at night and he would massage and shake the hand for relief, which the examiner noted was typical of carpal tunnel syndrome and not of diabetic neuropathy. The examiner noted that EMG testing, which confirmed the carpal tunnel syndrome, also demonstrated evidence of some diabetic peripheral sensory neuropathy in the hands, although the Veteran denied having any constant numbness or tingling in the hands. On neurologic examination, the Veteran denied all sensory limitations. The impressions included diabetes mellitus type 2 with the complication of some peripheral neuropathy (at least by EMG) in both hands, although the dominant symptoms seemed to be related to intermittent carpal tunnel syndrome. On February 2004 VA examination, the Veteran reported that his right arm had been numb for the previous 10 years, particularly when he awakened at night or when he drove a car. On physical examination, a motor examination (with the exception of the shoulder girdle muscles) was 5/5 for strength with good bulk and normal tone. The reflexes were trace in the upper extremities. No definite sensory findings could be seen. The examiner opined that it seemed unlikely that the Veteran has a peripheral neuropathy of the upper extremities, and it would not be related to his diabetes, since the symptoms occurred two to three years before the onset of the diabetes. The examiner opined that it may well be that he has a carpal tunnel syndrome which could be somewhat problematic for one who is a known diabetic. The examiner repeated that, in the absence of a carpal tunnel syndrome, he saw no evidence of neuropathic disease of the upper extremities. Following electromyography studies, the impressions included diabetic peripheral polyneuropathy with superimposed carpal tunnel syndromes. On March 2006 VA examination, the Veteran reported pain and numbness in the upper extremities. On physical examination, there was fair grasp, clenching, and fingering with decreased monofilament perception bilaterally over the palmar surfaces of the hands. The examiner opined that peripheral neuropathy was not present in the upper extremities. In March 2011, the Board remanded the matter to afford the Veteran a new VA examination to determine the current severity of the disability. On August 2011 VA peripheral nerves examination, the Veteran reported tingling in both hands and all ten fingers that would "come and go" but was present most of the time. He was noted to be right-handed by history and by observation. In addition to the numbness and tingling in his hands, he reported pain in his arms and forearms which flared with any type of pressure such as being touched on the arm or forearm. He reported dropping things almost daily due to the numbness and tingling in his hands. He reported difficulty opening lids of cans and jars and washing himself because it caused increased pain. He did not use hand tools. He cooked and baked but it caused him some pain and so he did less of both. He used no assistive devices for his upper extremities and took no medication for these symptoms. The main symptomatology involved numbness and tingling in the hands and fingers and pain in the arm and forearm. On physical examination, the Veteran revealed good muscle strength of the fist grip, measuring 4/5, and good muscle strength of flexion and extension and abduction of the right arm and forearm, measuring 4/5. Using a monofilament, there was normal sensation to light touch in the right arm and forearm, the hand, and all fingers. Deep tendon reflexes were 1+ at the elbow and absent at the wrist. The examiner noted that the Veteran had had numerous EMGs, most recently in 2006, all of which were normal with regard to the right upper extremity. On examination, the Tinel sign was negative and the Phalen test was questionably positive. The Veteran did not have tingling over the median nerve area, but did have pain in the arm, which would not be a classic positive response to the Phalen test; the examiner explained that the Phalen test was performed because the Veteran reported diagnoses of bilateral carpal tunnel syndrome which was not treated. The diagnoses included right upper extremity peripheral neuropathy. The Veteran has identified/submitted VA and non-VA treatment records through January 2012. Such records reflect symptoms similar to those noted on the VA examinations cited above. The reports of the VA examinations and the treatment records, overall, provide evidence against the Veteran's claim, as they do not show that symptoms of the Veteran's peripheral neuropathy of the right upper extremity produce impairment greater than mild incomplete paralysis of the median nerve, so as to meet the criteria for a rating greater than 10 percent. The Board notes the lay statements submitted by the Veteran in support of this claim. Those statements detail the types of problems that result from the Veteran's disability. The symptoms described do not show that the Veteran's peripheral neuropathy of the right upper extremity meets the criteria for a higher rating. In summary, it is not shown that the Veteran's peripheral neuropathy of the right upper extremity has at any time been manifested byimpairment greater than mild incomplete paralysis of the median nerve (or approximating such levels of severity). Consequently, a rating in excess of 10 percent is not warranted. Furthermore, the Board finds that the evidentiary record presents no reason to refer the case to the Compensation and Pension Service for consideration of an extra-schedular evaluation under 38 C.F.R. § 3.321(b). There is no evidence of symptoms or impairment not encompassed by the schedular criteria, so as to render those criteria inadequate. See Thun v. Peake, 22 Vet. App. 111 (2008). Finally, an April 1996 rating decision granted the Veteran a total disability rating based on individual unemployability. ORDER Service connection for a left ankle disability is denied. Service connection for a bilateral foot disability is denied. Service connection for a heart disability, including as secondary to service-connected diabetes mellitus, is denied. Service connection for a kidney disability, including as secondary to service-connected diabetes mellitus, is denied. A rating in excess of 10 percent for peripheral neuropathy of the right upper extremity is denied. ____________________________________________ George R. Senyk Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs