Citation Nr: 1324864 Decision Date: 08/05/13 Archive Date: 08/13/13 DOCKET NO. 05-37 825 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Manchester, New Hampshire THE ISSUES 1. Entitlement to service connection for a right foot disability. 2. Entitlement to service connection for a gastrointestinal disability, to include gastroenteritis. REPRESENTATION Appellant represented by: Peter J. Meadows, Attorney at Law ATTORNEY FOR THE BOARD K. Conner, Counsel INTRODUCTION The appellant served on active duty from October 1966 to July 1968. This matter originally came to the Board of Veterans' Appeals (Board) on appeal from a February 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in White River Junction, Vermont. As set forth above, the appellant's claims are now in the jurisdiction of the RO in Manchester, New Hampshire. In a November 2008 decision, the Board denied service connection for residuals of a right foot injury, residuals of a right ankle injury, and gastroenteritis. The appellant appealed the Board's decision to the U.S. Court of Appeals for Veterans Claims (Court). While the matter was pending before the Court, in March 2011, the appellant's attorney and a representative of VA's Office of General Counsel filed a joint motion for remand. Later that month, the Court granted the parties' motion, vacated the Board's November 2008 decision, and remanded the matter for action consistent with the March 2011 joint motion. In May 2012, the Board remanded the matter to the RO for additional evidentiary development and due process considerations. While the matter was in remand status, in a June 2013 rating decision, the RO granted service connection for residuals of a right ankle sprain and assigned an initial 10 percent disability rating, effective June 18, 2005. The grant of service connection for this disability constitutes a full award of the benefits sought on appeal with respect to that claim. See Grantham v. Brown, 114 F. 3d 1156 (Fed. Cir. 1997). The record currently available to the Board contains no indication that the appellant has initiated an appeal of the initial rating or effective date assigned. Thus, those matters are not currently before the Board. Id at 1158 (holding that a separate notice of disagreement must be filed to initiate appellate review of "downstream" elements such as the disability rating or effective date assigned). The Board also notes that while the matters discussed above were pending, the appellant continued to file additional claims at the RO. In a July 2011 rating decision, the RO granted service connection for posttraumatic stress disorder (PTSD) and assigned an initial 10 percent disability rating, effective January 4, 2011. In August 2011, the appellant initiated an appeal with the initial rating assigned. In an August 2012 rating decision, the RO increased the initial rating for the appellant's PTSD to 30 percent, effective January 4, 2011. Later that month, the appellant submitted a written statement indicating that he wished to withdraw his appeal of that matter. Under these circumstances, the issue of entitlement to an initial rating in excess of 30 percent for PTSD is not within the Board's jurisdiction. See Hamilton v. Brown, 4 Vet. App. 528 (1993) (en banc), aff'd, 39 F.3d 1574 (Fed. Cir. 1994) (holding that the Board is without the authority to proceed on an issue if the claimant indicates that consideration of that issue should cease). Additionally, the record shows that in an August 2011 determination, the RO denied the appellant's claim of entitlement to nonservice-connected pension. He submitted a notice of disagreement with the RO's determination later that month. In a June 2012 determination, the RO awarded nonservice-connected pension, effective February 1, 2011. Absent any indication in the record that the appellant appealed the RO's determination, there are no downstream matters currently before the Board with respect to this claim. Grantham, 114 F. 3d at 1158. Finally, the Board notes that in the March 2011 joint motion reference above, the parties agreed that the appellant must be afforded the opportunity to testify at a hearing at the RO. Pursuant to the Board's May 2012 remand instructions, the RO contacted the appellant and requested that he specify the type of hearing he wished to attend. In a February 2013 letter, however, the appellant's attorney indicated that the appellant did not wish to attend a hearing in connection with his appeal. Having received no further communication from the appellant or his attorney, the Board will proceed with consideration of the appeal, based on the evidence of record. FINDINGS OF FACT 1. A chronic right foot disability was not present during the appellant's active service, arthritis of the right foot was not manifest to a compensable degree within one year of separation from active duty, and the appellant's current right foot disability is not causally related to his active service or any incident therein, including a 1968 volleyball injury. 2. The appellant does not currently have gastroenteritis and his current celiac disease is not causally related to his active service or any incident therein, including a November 1966 episode of gastroenteritis. CONCLUSIONS OF LAW 1. A right foot disability was not incurred in active service, nor may right foot arthritis be presumed to have been incurred in active service. 38 U.S.C.A. §§ 1112, 1131, 1137, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.385 (2012). 2. A gastrointestinal disability, including gastroenteritis and celiac disease, was not incurred in active service. 38 U.S.C.A. §§ 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Veterans Claims Assistance Act of 2000 (VCAA) As a preliminary matter, the Board finds that no further notice or development action is necessary in order to satisfy VA's duties to the appellant under the VCAA. In June and November 2004 letters issued prior to the initial decision on the claims, VA notified the appellant of the information and evidence needed to substantiate and complete his claims, and of what part of that evidence he was to provide and what part VA would attempt to obtain for him. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b)(1) (2012). In March 2006, the RO provided the appellant with a letter for the express purpose of satisfying the additional notification requirements imposed by the Court in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Since the issuance of these letters, the RO has reconsidered the appellant's claim on multiple occasions, most recently in the June 2013 Supplemental Statement of the Case. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (holding that the issuance of a fully compliant VCAA notification followed by readjudication of the claim, such as an Statement of the Case or Supplemental Statement of the Case, is sufficient to cure a timing defect). With respect to VA's duty to assist, the record shows that VA has undertaken all necessary development action. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). The appellant has not argued otherwise. The appellant's service treatment records are on file, as are all available post-service clinical records which the appellant has specifically identified and authorized VA to obtain. 38 U.S.C.A. § 5103A(c) (West 2002); 38 C.F.R. § 3.159(c)(2), (3) (2012). In May 2012, the Board remanded the matter for the purpose of obtaining medical opinions with respect to the etiology of the appellant's claimed disabilities. As set forth in more detail below, the record on appeal now contains multiple examination reports and medical opinions. After reviewing the opinions obtained, the Board concludes that the record is adequate and that there has been substantial compliance with the Board's remand directives. D'Aries v. Peake, 22 Vet. App. 97, 104-05 (2008); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the appellant nor his attorney has argued otherwise. Sickels v. Shinseki, 643 F3d 1362 (Fed. Cir. 2011) (holding that in the absence of a challenge, the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination or opinion has been met. 38 C.F.R. § 3.159(c)(4) (2012). Finally, it is noted that VA's compliance with the VCAA was also addressed by the Board in its now vacated November 2008 decision. Neither the March 2011 joint motion for remand nor the Court's subsequent order vacating the Board's November 2008 decision, however, contains any reference to VCAA notice or development deficiencies or the Board's discussion thereof. In light of the Court's repeated admonitions regarding the undesirable specter of piecemeal litigation, the Board is confident that if there had been any prejudicial deficiencies regarding VA's compliance with its duty to notify or assist, such would have been raised by the Court. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). For the reasons set forth above, and given the facts of this case, the Board finds that no further notification or development action is necessary on the issues now being decided. Background In pertinent part, the appellant's service treatment records show that in November 1966, he sought treatment for multiple complaints, including diarrhea, aching, and chills. He was diagnosed as having an upper respiratory infection and gastroenteritis. In January 1968, the appellant sought treatment after he reportedly sprained his left ankle while playing volleyball. The examiner noted that the results of an X-ray were negative for fracture. No other complaints or abnormalities were identified. In July 1968, X-ray studies of both of the appellant's feet were negative. At his July 1968 military separation medical examination, clinical evaluation of the appellant's abdomen, feet, and lower extremities showed that no abnormalities were present. In connection with the examination, the appellant completed a report of medical history on which he denied having or ever having had frequent indigestion, stomach or intestinal trouble, and foot trouble. In June 2004, the appellant submitted an original application for VA compensation benefits, seeking service connection for right foot and ankle disabilities, which he indicated had been incurred in April 1968. In November 2004, he submitted a claim of service connection for gastroenteritis, reporting that he had been diagnosed as having that condition during service. In support of his claim, the RO obtained VA clinical records showing that in November 2004, the appellant sought to initiate medical care with VA. He reported that he had been working as a carpenter, construction worker, and truck driver for the past 40 years and had had no prior regular medical care. His main complaints included a multi-year history of chronic joint pain, particularly in the right foot where he recalled sustaining a severe right ankle sprain in the Army in 1968. The impression was long history of joint pain in multiple heavy use areas, likely osteoarthritis Patient has not had proper health management since discharge from the Army in 1968. X-ray studies of the appellant's feet in November 2004 showed bilateral severe hallux valgus deformities and fusion of the tarsal and metatarsal bones. Subsequent VA clinical records show that the appellant continued to receive treatment for multiple conditions, including right foot and ankle pain which he reported had been present for the past thirty years. Diagnoses included pes cavus, plantar calcaneal bursitis, and osteoarthritis. In a March 2009 statement, the appellant indicated that although his service treatment records noted that he had injured his left ankle playing volleyball in service, he had actually injured his right foot and ankle at that time. He indicated that his service treatment records were inaccurate because he knew that he had injured his right foot and ankle, not his left. In a February 2010 medical opinion, a VA examiner noted that the appellant's service treatment records documented one episode of ankle sprain in 1968 and that X-ray studies of the ankle following the injury had been negative. She further noted that X-ray studies of the appellant's feet in 1968 had been negative. She indicated that it was very unlikely that one ankle strain in 1968 was responsible for the significant bilateral degenerative changes currently evident in the appellant's feet. Rather, she explained that the appellant's current bilateral foot pathology was consistent with his occupational history of working for 40 plus years as a carpenter, construction worker, and truck driver. In a March 2012 letter, a private counselor noted that the appellant had reported a history of injuring his right ankle and foot in service and having had regular pain and stiffness since that time. The counselor indicated that it appeared more likely than not that the residuals of a right foot and ankle injury had their origins in service. Regarding the appellant's gastroenteritis, the counselor noted that the appellant became ill with this disorder in service and had since developed what appeared to be chronic gastroenteritis. The counselor indicated that it appeared more likely than not that the appellant's gastroenteritis had its origin in service. Additional VA clinical records show that the appellant continued to receive VA treatment for multiple conditions. During a physical in July 2009, the appellant denied abdominal pain, nausea, vomiting, diarrhea, or constipation. He said his indigestion was better when he was eating a healthier diet. He reported some intestinal gas, stating that it was trigged by some foods. In May 2011, the appellant again denied abdominal pain, nausea, and vomiting. He reported occasional indigestion with the wrong foods. In October 2011, the appellant denied abdominal pain, nausea, and indigestion. In September and October 2012, the appellant was seen in connection with his complaints of persistent lower abdominal and gastrointestinal symptoms of unknown etiology. Diagnostic testing resulted in a diagnosis of celiac disease in November 2012. In April 2013, the appellant underwent VA medical examination. He reported that he had injured his right foot at ankle in service during a volleyball game. He recalled that his right foot and ankle became painful, swollen and ecchymotic. He indicated that he had been unable to wear a boot for the next two months due to swelling. The appellant reported that his right foot and ankle had since been painful, particularly when standing for prolonged periods. The examiner noted that the appellant's service treatment records reflected a left ankle injury but that the appellant reported that it was his belief the author of the medical note had mistakenly written left instead of right. After examining the appellant and reviewing the record, the examiner's diagnoses included bilateral hallux valgus, claw foot (pes cavus), and degenerative joint disease of the feet. The examiner indicated that although the appellant's current right ankle disability was as likely as not related to the in-service right ankle injury, his current right foot disability was not. He explained that the appellant's current foot pathology was bilateral and symmetric, not just in the right foot. He further indicated that it was unlikely that a single ankle sprain in service had led to the current bilateral foot findings evident on examination. Rather, he indicated that he agreed with the previous VA examiner that the symmetric findings in the appellant's feet were more likely the cumulative result of years of working on his feet in the construction trade and not the result of the single in-service ankle strain. The examiner indicated that he had reviewed the opinion provided by the private counselor but found it to be of little probative value. He explained that the individual held a degree in counseling but had no medical degree which rendered his credentials of limited value regarding physical diagnoses and etiologies. At a VA medical examination in April 2013, the appellant reported that he had developed a diarrheal illness in Vietnam. His entire unit had been sick with the same symptoms, causing a shutdown of the mess hall. He recalled that the outbreak of illness was traced to food contamination due to poor sanitation practices by the cooks. The appellant reported that since that time, he had suffered from bloating, gurgling, and cramps, as well as episodes of sharp pain in the lower abdomen. The appellant indicated that he had recently been diagnosed as having celiac disease. The examiner noted that service treatment records reflected that the appellant had been treated for symptoms of an upper respiratory infection and diarrhea in November 1966 and had been diagnosed as having gastroenteritis. He noted that VA clinical records reflected that in November 2012, the appellant had been diagnosed as having celiac disease. The appellant had been following a gluten free diet since that time and had had a 60 percent reduction in his symptoms. After examining the appellant and reviewing the record, the examiner diagnosed the appellant as having celiac disease. He explained that there was no evidence on current examination or in any of the records reviewed that the appellant currently had any other gastrointestinal condition. He explained that although the exact etiology of celiac disease was unknown, it likely involved a combination of genetic and immune disorders. Although the appellant had an isolated episode of acute gastroenteritis in service, there was no suggestion in the medical literature that celiac disease was caused by isolated cases of acute gastroenteritis. The examiner indicated that he had reviewed the opinion provided by the private counselor but found it to be of little probative value. He explained that the individual held a degree in counseling but had no medical degree which rendered his credentials of limited value regarding physical diagnoses and etiologies. Applicable Law Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty or for aggravation of a pre-existing injury or disease in the line of duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2012) Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d) (2012). Service connection for certain enumerated chronic diseases, including arthritis, may also be established on a presumptive basis by showing that such a disease manifested itself to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. § 1112, 1137 (West 2002); 38 C.F.R. § 3.307, 3.309 (2012). In such cases, the disease is presumed under the law to have had its onset in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a) (2012). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See e.g. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). In some cases, service connection may also be established under 38 C.F.R. § 3.303(b) by evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C.A. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Analysis Right foot disability The appellant seeks service connection for a right foot disability. He contends that he sustained a right foot and ankle injury in service while playing volleyball. He argues that his post-service chronic right foot disability is related to that in-service injury. After carefully considering the record on appeal, the Board finds that the preponderance of the evidence is against the claim. As set forth above, the appellant's service treatment records show that in January 1968, the appellant sought treatment after he reportedly sprained his left ankle while playing volleyball. The appellant, however, has provided statements to the effect that his right lower extremity was injured, not his left, and that the treatment provider mistakenly recorded the left ankle. The Board finds that the appellant's statements are credible. That an injury occurred in service, however, is not enough to establish service connection. Rather, there must be chronic disability resulting from that in-service injury. In this case, the evidence establishes that the appellant did not develop a chronic right foot disability during service. As set forth above, the appellant's service treatment records are entirely negative for complaints of right foot pathology. Indeed, in July 1968, X-ray studies of both of the appellant's feet were negative. Also in July 1968, the appellant completed a report of medical history on which he denied having or ever having had foot trouble. Moreover, clinical evaluation of the appellant's feet at that time showed that no abnormalities were present. The Board notes that the post-service record similarly contains no indication of arthritis of the right foot within the first post-service year or, indeed, for many years thereafter. As noted, the appellant reports that he did not receive regular medical care until 2004. Although the record establishes that a chronic right foot disability was not present during the appellant's active service or manifest to a compensable degree within one year of service separation, as set forth above, service connection may nonetheless be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In this case, however, the Board finds that the most probative evidence of record establishes that the appellant's current right foot disability is not causally related to the appellant's active service or any incident therein, including his January 1968 right foot and ankle injury. In that regard, the record contains conflicting evidence regarding the etiology of the appellant's current right foot disability. As set forth in more detail above, in a February 2010 medical opinion, a VA examiner concluded that it was unlikely that the in-service volleyball injury of the right lower extremity was responsible for the current significant bilateral degenerative changes currently evident in the appellant's feet. Rather, she explained that the appellant's current foot pathology was consistent with his occupational history of working for 40 plus years as a carpenter, construction worker, and truck driver. Similarly, in an April 2013 medical opinion, a VA physician diagnosed the appellant as having bilateral hallux valgus, claw foot (pes cavus), and degenerative joint disease of the feet. He explained that the appellant's current foot pathology was bilateral and symmetric, not just in the right foot, and that it was unlikely that a single sprain in service had led to the current bilateral foot findings. Rather, he indicated that he agreed with the previous VA examiner that the symmetric findings in the appellant's feet were more likely the cumulative result of years of working on his feet in the construction trade and not the result of the single in-service ankle strain. On the other hand, the record also contains the March 2012 letter from the appellant's private counselor who noted that it appeared more likely than not that the residuals of a right foot injury had its origins in service. In considering these conflicting medical opinions, the Board notes that the Court has provided "important, guiding factors to be used by the Board in evaluating the probative value of medical opinion evidence." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). These factors are (1) The opinion is based upon sufficient facts or data. In other words, is the medical professional informed of sufficient facts upon which to base an opinion relevant to the problem at hand?; (2) The opinion is the product of reliable principles and methods; and (3) The expert has applied the principles and methods reliably to the facts of the case. In other words, most of the probative value of a medical opinion comes from its reasoning. After carefully considering conflicting opinions discussed above in light of the criteria outlined in Nieves-Rodriguez, the Board finds that the VA medical opinions outweigh that of the private counselor. First, the Board observes that the VA examiners had the benefit of both physically examining the appellant and reviewing the entire claims folder and VA clinical records, including the service treatment records, which contain 1968 X-ray studies of the appellant's feet, as well as the post-service clinical records, including additional diagnostic studies. These clinical examinations and diagnostic test results more clearly defined the nature and etiology of the appellant's current right foot pathology. The private counselor's opinion was based only on the nature of the injury and symptoms as described by the appellant while the VA examiners had the benefit of considering both the appellant's reports of the in-service injury, in-service and post-service symptoms, and clinical evidence of treatment provided immediately following the injury as well as subsequent service treatment records. The Board notes that the VA examiners' opinions included specific reference to the clinical record, lending greater credibility and probative weight to their conclusions regarding the matter at issue in this case. Again, the VA examiners also had the benefit of a physical examination of the appellant. There is no indication that the private counselor examined the appellant's feet clinically. The Board further observes that the counselor's opinion is also framed in speculative terms, unlike that of the VA examiners. Finally, as noted by the VA physician in April 2013, the appellant's counselor lacks the education, training, and expertise necessary to provide an opinion regarding the nature and etiology of physical conditions such as a foot disability or arthritis. Both VA medical examiners, on the other hand, are qualified medical professionals, a nurse practitioner and a physician. For all of these reasons, the Board concludes that the VA medical opinions are more probative as to the nature and etiology of the appellant's current right foot disability. The Board has also considered the appellant's statements to the effect that his right foot has long been symptomatic and he believes his current right foot disability was incurred in service as a result of his volleyball injury. The Board finds that the appellant's statements, when weighed against the evidence discussed above, do not provide a basis upon which to grant the claim. The Board finds that the probative value of the appellant's statements is outweighed by the more qualified VA physician and nurse practitioner who provided the opinions discussed above. Again, these medical professionals considered the entire record on appeal, including the history reported by the appellant, medical records contemporaneous to the in-service injury, the post-service record on appeal, and a current medical evaluation of the appellant. After considering all of these factors, they nonetheless both concluded independently that the appellant's current right foot disability is not causally related to his active service, including his volleyball injury. Their consideration of this evidence, and the detailed explanation they provided, lend great probative weight to their opinions. In summary, the Board finds that the most probative evidence establishes that the appellant's current right foot disability was not present during his active service or manifest to a compensable degree within the first post-service year and the most probative evidence establishes that his current right foot disability is not causally related to the appellant's active service or any incident therein, including the 1966 volleyball injury. The Board concludes that the preponderance of the evidence is against the claim and the benefit of the doubt doctrine is not for application. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Gastrointestinal disability, to include gastroenteritis The appellant also seeks service connection for a gastrointestinal disability, specifically gastroenteritis. He argues that he was diagnosed as having gastroenteritis during service and that he continues to suffer from gastrointestinal symptoms. After carefully considering the record on appeal, the Board finds that the preponderance of the evidence is against the claim. As set forth above, the appellant's service treatment records confirm that the he was treated for an episode of gastroenteritis in 1966. These records further indicate, however, that his gastroenteritis resolved without sequelae. In that regard, the remaining service treatment records are entirely negative for any indication of gastroenteritis or other gastrointestinal disability. Indeed, at his July 1968 military separation medical examination, the appellant completed a report of medical history on which he denied having or ever having had frequent indigestion and stomach or intestinal trouble. The Board has considered the appellant's statements to the effect that he has experienced longstanding gastrointestinal symptoms. As set forth in detail above, the appellant reports that he received no regular medical care until he initiated care with VA in November 2004. A review of these records shows that in more recent years, the appellant has reported episodic indigestion particularly with certain foods, and in November 2012, he was diagnosed as having celiac disease. No other gastrointestinal disability is identified in the post-service clinical records. In April 2013, a VA physician examined the appellant and reviewed the record. After so doing, he diagnosed the appellant as having celiac disease and concluded that there was no evidence on current examination or in any of the records reviewed that the appellant currently had any other gastrointestinal condition. The VA physician further explained that the appellant's celiac disease was not related to his active service or any incident therein, including his episode of gastroenteritis. The Board finds that the April 2013 VA medical opinion is persuasive and assigns it great probative weight. The opinion was rendered by a physician, a medical professional with the expertise necessary to opine on the question at issue in this case. In addition, the examiner interviewed and examined the appellant and reviewed his claims folder, factors which further increase the weight of his opinion. The examiner specifically addressed the appellant's medical history, the contentions presented, and provided a rationale for his conclusion, noting that the medical literature indicated that celiac disease was likely caused by a combination of genetic and immune disorders, with no suggestion that it could be induced by acute gastroenteritis. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (discussing "important, guiding factors" to be used in determining the probative value of medical opinions). The Board has also considered the March 2012 letter from the appellant's counselor who noted that the appellant had developed what appeared to be chronic gastroenteritis and that such condition appeared to have had its origin in service. In light of the criteria outlined in Nieves-Rodriguez, however, the Board assigns this opinion limited probative value. First, the Board observes that the private counselor did not have the benefit of conducting a physical examination of the appellant in connection with a review of the entire claims folder, which included diagnostic tests results such as celiac antibody results, which more clearly defined the nature and etiology of the appellant's gastrointestinal symptoms. The counselor's opinion is also speculative, noting that the appellant had "what appeared to be" chronic gastroenteritis. Finally, as noted by the VA physician, the appellant's counselor lacks the education, training, and expertise necessary to provide an opinion regarding the nature and etiology of physical conditions such as celiac disease or gastroenteritis. For all of these reasons, the Board concludes that the April 2013 VA medical opinion is more probative as to the nature and etiology of the appellant's current gastrointestinal condition. The Board has also considered the appellant's statements to the effect that he believes he developed chronic gastroenteritis in service. The Board finds that the appellant's statements, when weighed against the evidence discussed above, do not provide a basis upon which to grant the claim. The Board finds that the probative value of the appellant's opinion, even considering his experience as a military medic, is outweighed by the more qualified VA physician who provided the opinion discussed above. Again, the VA physician considered the entire record on appeal, including the history reported by the appellant, medical records contemporaneous to the in-service gastroenteritis, the post-service record on appeal, and a current medical evaluation of the appellant. After considering all of these factors, he nonetheless concluded that the appellant currently has celiac disease, not chronic gastroenteritis, and that his celiac disease is not causally related to his active service. The physician's consideration of this evidence, and the detailed explanation he provided, and his medical degree, lends great probative weight to his opinion. In summary, the Board finds that the most probative evidence shows that the appellant's in-service episode of gastroenteritis in 1966 resolved without residual disability, that he does not currently have gastroenteritis, and that his current celiac disease is not causally related to his active service or any incident therein, including the 1966 episode of gastroenteritis. For these reasons, the preponderance of the evidence is against the claim of service connection for a gastrointestinal disability, including gastroenteritis and celiac disease. 38 U.S.C.A. § 5107(b). ORDER Entitlement to service connection for a right foot disability is denied. Entitlement to service connection for a gastrointestinal disability, to include gastroenteritis and celiac disease, is denied. ______________________________________________ Cheryl L. Mason Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs