Citation Nr: 1327286 Decision Date: 08/26/13 Archive Date: 08/29/13 DOCKET NO. 07-24 243A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Chicago, Illinois THE ISSUE Entitlement to service connection for bilateral foot disorders, to include plantar fasciosis and right foot calcaneal spur (hereinafter "right foot spur"). REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD A. Nigam, Counsel INTRODUCTION The Veteran served on active duty from October 1963 to October 1965. This matter initially came before the Board of Veterans' Appeals (hereinafter "Board") on appeal from a September 2007 decision issued in October 2007 by the Department of Veterans Affairs (hereinafter "VA") Regional Office (hereinafter "RO") in Chicago, Illinois. In this decision, the Veteran was denied entitlement to service connection for right foot hallux valgus. In August 2009, the Veteran testified at a hearing before the undersigned Veterans Law Judge (hereinafter "VLJ"). A transcript of that proceeding is of record. In March 2010, the Board, inter alia, remanded the claim to the RO via the Appeals Management Center (hereinafter "AMC"), in Washington, DC for further development of the record, to include ordering that a new VA examination and clarifying medical opinion be obtained. In an August 2011 decision, the Board denied the claim, which was thereafter the subject of an April 2012 Joint Motion for Partial Remand (hereinafter "JMPR") and a May 2012 Order of the United States Court of Appeals for Veterans Claims (hereinafter "the Court"), because the Board was found to have erred by failing to provide an adequate statement of reasons or bases for the denial of the Veteran's claim. In January 2013, the Board remanded the claim to the RO via the AMC, for additional development of the record, to include providing VA examination and clarifying medical opinion. Following its completion of the Board's requested actions, the AMC continued the denial of the Veteran's claim for service connection as reflected in a March 2013 supplemental statement of the case (hereinafter "SSOC"). In evaluating this case, the Board has not only reviewed the physical claims file, but has also reviewed the eFolder on Virtual VA (hereinafter "Virtual VA") to ensure a complete assessment of the evidence. Additional, pertinent medical evidence was added to Virtual VA in January 2013 and February 2013, which was considered by the AMC in the March 2013 SSOC. Moreover, the Veteran submitted a waiver of RO consideration of this evidence in March 2013, which the Board accepts for inclusion into the record. As such, the Board will proceed to consider the appeal on the merits. See 38 C.F.R. §§ 20.800, 20.1304(c) (2012). In May 2013, in accordance with 38 U.S.C.A. § 7109 and 38 C.F.R. § 20.901, the Board also obtained a medical opinion from the Veterans Health Administration (hereinafter "VHA"). The Veteran and his representative have been provided with a copy of the VHA opinion, and a copy has been associated with the claims file. FINDINGS OF FACT 1. All notification and development actions needed to fairly adjudicate the matter on appeal have been accomplished. 2. The Veteran's bilateral foot disorders are not shown to have developed as a result of an established event, injury, or disease during active service. CONCLUSION OF LAW The Veteran's bilateral foot disorders were not incurred or aggravated in service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board must consider and discuss all applicable statutory and regulatory law, as well as the controlling decisions of the appellate courts. The Board's duty is to determine the probative value of all pertinent medical and lay evidence of record based on its credibility and competency, and then weigh the probative value of the evidence regarding all material elements of a claim. See 38 U.S.C.A. § 7104(d); Kahana v. Shinseki, 24 Vet. App. 428, 433 (2011); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). A "veteran is given the 'benefit of the doubt' 'regarding any issue material' to the veteran's claim 'when there is an approximate balance of positive and negative evidence.'" Fagan, 573 F.3d at 1287 (quoting 38 U.S.C. § 5107(b)). Thus, if there is conflicting medical evidence, the Board may not ignore or disregard any medical professional's opinion, but may assign greater probative to one medical opinion over by providing an adequate statement of reasons or bases for doing so. See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Willis v. Derwinski, 1 Vet. App. 66, 70 (1991). A medical opinion is most probative if it is factually accurate, fully articulated, and based on sound reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). In making all determinations, the Board must also fully weigh the probative value of the lay evidence of record against the remaining evidence of record. See King v. Shinseki, No. 2011-7159 (Fed. Cir. Dec. 5, 2012). If credible, 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 lay person. 38 C.F.R. § 3.159(a). Thus, a layperson is competent to report on the onset and continuity of his symptomatology. See Kahana, 24 Vet. App. at 438; Layno, 6 Vet. App. at 470 (a veteran is competent to report on that of which he or she has personal knowledge). Moreover, lay evidence must not be categorically dismissed as incompetent evidence of medical causation merely because it is lay evidence. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Rather, lay evidence may be competent and sufficient evidence of a diagnosis or nexus if (1) the particular condition at issue is the type of condition that is within the competence of a layperson, (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. See Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); see also Kahana, 24 Vet. App. at 433, n.4. The Board must determine on a case-by-case basis whether a particular condition is the type of condition that is within the competence of a lay person. See Jandreau, 492 F.3d 1367-77; see also Kahana, 24 Vet. App. at 438, J. Lance dissenting; Robinson v. Shinseki, 312 Fed. Appx. 336, 339 (Fed. Cir. 2009) (nonprecedential). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107 (West 2002). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See 38 C.F.R. § 3.102. When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (hereinafter "VCAA") describes VA's duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the Veteran and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim, and to indicate which information and evidence VA will obtain and which information and evidence 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, 486 (2006). The notice must be provided to the Veteran prior to the initial adjudication of his claim. Pelegrini v. Principi, 18 Vet. App. 112 (2004). VA has satisfied its duty to notify by issuing pre- and post-adjudication notice letters in March 2005, November 2006, February 2007, May 2010 and July 2010. These letters advised the Veteran of what evidence was required to substantiate his claim for service connection, and of his and VA's respective duties for obtaining evidence. The November 2006, February 2007 and May 2010 letters also provided notice regarding the disability evaluation and effective date elements of a service connection claim. Dingess, 19 Vet. App. at 473. As noted, the claim was most recently readjudicated in the March 2013 SSOC. Accordingly, prejudicial error in the timing or content of VCAA notice has not been established and any error is not outcome determinative. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency). Further, if any notice deficiency is present in this case, the Board finds that any prejudice due to such error has been overcome by the following: (1) based on the communications sent to the Veteran over the course of this appeal, he clearly has actual knowledge of the evidence he is required to submit in this case; and (2) based on the Veteran's contentions as well as the communications provided to him by VA, it is reasonable to expect that he understands what was needed to prevail. See Shinseki v. Sanders/Simmons, 129 S. Ct. 1696 (2009); Fenstermacher v. Phila. Nat'l Bank, 493 F.2d 333, 337 (3d Cir. 1974) ("[N]o error can be predicated on insufficiency of notice since its purpose had been served."). In order for the Court to be persuaded that no prejudice resulted from a notice error, "the record must demonstrate that, despite the error, the adjudication was nevertheless essentially fair." Dunlap v. Nicholson, 21 Vet. App. 112, 118 (2007). The duty to assist provisions of the VCAA have been met. The claims file contains the Veteran's, his friends' and his family's lay statements and hearing testimony, pre-service and post-service medical treatment records, and reports of VA examinations and addenda (also known in the record as Disability Benefits Questionnaires or "DBQs") dated in September 2005, July 2010 and February 2013. Moreover, VA has obtained a VHA medical expert opinion to address the nature and etiology of the Veteran's claimed bilateral foot disorders. The Board finds that the VA examinations and VHA opinion, when considered together, are adequate to decide the case because, as shown below, they were based upon consideration of the Veteran's pertinent medical history, lay assertions, and current complaints and because they describe the claimed back disorder in detail sufficient to allow the Board to make a fully informed determination. Barr v. Nicholson, 21 Vet. App. 303 (2007) (citing Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Additionally, as noted, this case was remanded in May 2010 and January 2013 to obtain outstanding treatment records, and VA examination and clarifying medical opinion, which have been obtained and considered by the AMC. All VA treatment records have been obtained and associated with the claims file and Virtual VA. The Veteran did not identify any further pertinent evidence that remains outstanding, nor has he submitted a VA Form 21-4142, Authorization and Consent to Release of Information to the Department of Veterans Affairs (hereinafter "Form 21-4142"), to obtain any such records. In July 2010 and February 2013, the Veteran underwent VA examination for his claimed bilateral foot disorders. These examinations and the accompanying addenda, along with the recently obtained VHA opinion, are adequate for VA rating purposes for the reasons articulated above. Therefore, the record shows substantial compliance with the May 2010 and January 2013 remand directives and no further development is required. See Stegall v. West, 11 Vet. App. 268 (1998); Dyment v. West, 13 Vet. App. 141 (1999). At the August 2009 hearing, the undersigned VLJ and representative for the Veteran outlined the issue on appeal and engaged in a colloquy as to substantiation of the claim. Overall, the hearing was legally sufficient and the duty to assist has been met. 38 U.S.C.A. § 5103A (West 2002 & Supp. 2012); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Veteran has not made the RO, the AMC or the Board aware of any additional evidence that must be obtained in order to fairly decide the claim on appeal. He has been given ample opportunity to present evidence and argument in support of his claim. Pursuant to 38 C.F.R. § 3.655, all relevant evidence necessary for an equitable disposition of the Veteran's appeal of the issue has been obtained and the case is ready for appellate review. The Board additionally finds that general due process considerations have been complied with by VA. See 38 C.F.R. § 3.103 (2012). The Merits of the Claim Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection generally requires credible and competent evidence showing: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship ("nexus") between the present disability and the disease or injury incurred or aggravated during service. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet .App. 247, 253 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). "Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability. In the absence of a proof of present disability there can be no claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement of a "current disability" is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal; service connection may be awarded even though the disability resolves prior to adjudication of the claim. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Certain chronic diseases, which are listed in 38 C.F.R. § 3.309(a) may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active service. 38 U.S.C.A. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. If a disease listed in 38 C.F.R. § 3.309(a) is shown to be chronic in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. Id. If chronicity in service is not established or where the diagnosis of chronicity may be legitimately questioned, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. § 3.303(b). A claimant "can benefit from continuity of symptomatology to establish service connection in the ultimate sense, but only if [the] chronic disease is one listed in § 3.309(a)." Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In the present case, the Board finds, after careful consideration of all relevant evidence that the preponderance of the more probative evidence weighs against the claims for service connection for bilateral foot disorders. Service treatment records indicate that the Veteran complained of right foot trauma, and the Veteran was ordered an X-ray study to rule out a fracture. An undated X-ray report revealed no significant abnormalities were found on X-ray. The Veteran also complained of left ankle pain, treated with hot soaks and light duty, in November 1963. Post-service, private treatment records reveal the Veteran complained of arch, calf and foot pain and tiredness following prolonged ambulation, and was diagnosed with right foot disorders, to include early hallux limitus in the right foot, symptomatic pronation in both feet, calcaneal spur syndrome and plantar fasciitis as early as September 1985. It was noted at that time that the Veteran's job involved a "great deal of walking." In a statement received in June 2004, the Veteran reported that when he entered basic training in October 1963, he was issued shoes that were one and a half sizes too small, and that he complained about his feet being sore for approximately several months prior to his superiors sending him to sick call to seek treatment. He indicated that the treating military physician was able to discern a pattern of erosion on the bottom of his boot sole, which led to his being issued new boots that fit him properly and discontinued some of the pain and discomfort. The Veteran noted that in January 1964, when he was transferred to the Republic of Vietnam (hereinafter "Vietnam"), he continued to complain of pain and discomfort. He indicated that upon discharge from the military, the Veteran reported that he experienced problems with his feet, legs and back. He noted that the physician who was clinically evaluating him gave him the option of undergoing a corrective operation involving the insertion of plastic wedges in his feet, which would require him to remain in service for six additional months for the operation and rehabilitation. He reported that he elected not to undergo surgery at that time, and indicated that his problems with his feet continued until September 1985 when he sought treatment at a foot clinic to see if anything could be done to relieve some of his pain. He noted that it was at the clinic that he was fitted with special arch supports, which relieved some of his pain. The record demonstrates evidence of in-service treatment to the feet, as well as post-service treatment for a current bilateral foot disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Thus, with consideration of the above-undisputed facts, the central question before the Board concerns whether the record contains medical nexus evidence establishing a connection between the in-service treatment to the feet and the post-service treatment for a bilateral foot disability. See id. On this question, there is some evidence supporting this claim and some evidence weighing against this claim. Weighing in favor of the claim are lay statements from the Veteran's friends and family members, received in April 2005, which indicate observations that, prior to his entry into military service the Veteran had not experienced any foot problems; however, after his separation from service, he experienced symptoms of foot pain, swelling and difficulty walking. The Board finds that these lay statements are competent evidence that the Veteran experienced post-service foot pain, swelling and difficulty walking, as the Veteran's friends and family are deemed competent to report observable symptoms for the feet, including difficulty walking. Washington, 19 Vet. App. at 368; Layno, 6 Vet. App. at 469. See also 38 C.F.R. § 3.159(a)(2). However, the Board notes that these statements generally indicate that the Veteran's feet were physically sound prior to his entering service, and showed signs of problems since service, but do not reflect observations that the Veteran experienced continuous bilateral foot disorders since his separation from service. In fact, two of the Veteran's friends who submitted statements of their lay observations had not known the Veteran for more than 9 and 17 years prior to providing their statements. Also, the Board finds that the question of whether the Veteran currently experiences bilateral foot disorders that are related to his in-service foot problems is a complex medical question outside the competence of a layperson. Neither the Veteran nor his friends or family have been shown to have the diagnostic capabilities to determine that the foot problems he experienced in service were not resolved in service, and that the current foot disorders developed as the result of post-service employment or injury. Their opinions are therefore not competent evidence of a diagnosis or etiology. See Kahana, 24 Vet. App. at 433, n.4; Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. In September 2005 the Veteran underwent a VA feet examination, during which the Veteran reported that he had been treated in 1963 for right foot pain while in service, that he was issued boots that were too small while in basic training, and that it took 5 months to get refitted for new boots despite his complaints of foot pain. The Veteran indicated that he continued to experience bilateral foot pain but did not begin to undergo medical treatment for his feet until 1985. The Veteran reported that he had shoe inserts customized for him in 1985, that he was treated for plantar fasciitis and heel spur 8 months prior, and that he was administered steroid injections for his heel spur or two occasions and underwent physical therapy for his plantar fasciitis. The examiner ultimately opined that the Veteran's current right foot disabilities, to include plantar fasciitis and a history of right calcaneal spur, were not likely related to his military service. The examiner explained that the Veteran's report of foot pain during service was not found in the service treatment records, and that there was no documentation of any foot problems or deformity in the service treatment records. A medical opinion based on an incorrect factual premise is not probative. Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). In this case, the September 2005 VA examiner based the medical opinion on part of a finding that the Veteran never complained of foot pain during his military service. As indicated above, however, the service treatment records do confirm the Veteran complained of right foot trauma and bilateral ankle pain. Although X-rays at the time were negative, there clearly was documentation of in-service complaints of foot pain. Accordingly, the September 2005 VA examination is inadequate because it is based on an incorrect factual premise. Id. The Veteran has testified in his August 2009 hearing that he was issued boots that were too small for him at the time of induction into service, and that he was forced to go through basic training with them, after which time he was issued jungle boots. He reported that he sought treatment for his right foot approximately 7 years after his discharge from service. He indicated that he could not afford medical treatment until he obtained his first job after service, which was approximately 7 years after separation, and that he did not seek treatment for his feet because "[he] was just happy to be out and nothing seemed to bother [him] that much..." He also reported that he did not begin to receive orthopedic treatment, such as wearing orthopedic shows and arch supports until 20 years after his separation from service. He noted that he was wearing orthopedic implants at the time of the hearing. In July 2010, the Veteran underwent a second VA feet examination, during which the examiner diagnosed the Veteran with an impression of bilateral flexible pes planus, bilateral plantar fasciosis, and right hallux rigidus. The examiner observed that the Veteran has flexible pes planus which is a developmental/hereditary condition of childhood, and obviously preexisted his military service. The examiner noted that this condition affected approximately 15 percent of the general population and might or might not have been symptomatic. The examiner indicated that, arguably, this condition could have been temporarily aggravated, as indicated by an increase in pain, by military service, but opined that there was little or no reason to believe that the condition would be permanently worsened beyond what would be expected from its natural history by military service. The examiner noted that although plantar fasciosis was commonly seen in those with normal foot alignment, it was recognized that foot pronation caused by the pes planus, predisposed the foot to the development of plantar fasciosis. The examiner observed that similarly, it was recognized that foot pronation predisposed the foot to the development of hallux rigidus. The examiner indicated that, after review of the Veteran's X-ray studies, which demonstrated extensive degenerative changes of the right hallux metatarsophalangeal joint, it was surprising that the Veteran was asymptomatic in regard to this joint. The examiner explained that plantar fasciosis was a degenerative condition and not an inflammatory condition of the plantar fascial origin; hence, this condition was presently referred to as a fasciosis rather than a fasciitis. The examiner noted that plantar fasciosis was a common condition in the general population affecting approximately 10 percent of the general population at some point in their life, and was a condition that was particularly common in runners. The examiner characterized the condition as a repetitive use "micro-trauma" that would not be caused by a single traumatic event. The examiner noted that a traumatic event could cause disruption of the plantar fascia; however, this mechanism played no role in the development of plantar fasciosis. It was once thought that a heel spur was the cause of this condition; however, the examiner noted that this concept had been essentially disregarded and most authorities believed that a heel spur, if present, was not a pain generator. The examiner observed that a heel spur was often noticed as an incidental finding on X-ray in those who did not have plantar fasciosis and many of those, if not most, with plantar fasciosis did not have heel spurs. The examiner commented on the Veteran's specific contentions, and opined that there was little evidence that poor fitting shoes/boots would cause anything more than blisters or calluses; although some believed tight shoe boxes could cause hammertoes, but this was considered unlikely by most authorities. The examiner concluded that there was nothing in the medical literature to suggest that plantar fasciosis was caused by poor fitting shoe wear. Further, the examiner noted that the service treatment records, which documented a right foot injury/condition and a left ankle injury, and opined that without a specific diagnosis of plantar fasciosis/fasciitis being made at that time any association with the foot condition at that time to the present plantar fasciosis would be merely speculative. The examiner observed that there were obviously a myriad of foot conditions other than plantar fasciosis, but concluded that an ankle injury would have no relationship to the development of plantar fasciosis. The examiner noted that the Board's March 2010 remand indicated that the Veteran was treated for a right foot condition as little as seven years following separation from service, but that those records were not available, and thus no meaningful diagnosis could be established. However, the examiner concluded that even if those records provided a diagnosis of plantar fasciosis, a seven-year span would make it difficult to attribute that condition to the foot condition that existed during service. The examiner noted that in the vast majority of cases, symptoms related to plantar fasciosis lasting more than one year was unlikely. However, this condition could develop at a later time, in fact on multiple occasions, as an isolated event unrelated to the original condition. The examiner concluded that this would not represent a chronic condition. The examiner opined that it was more likely than not that the Veteran's present condition of plantar fasciosis was not related to military service. The Board notes that the examiner did not address whether the Veteran's pes planus was a congenital disease or defect, but merely called it a congenital "condition." Congenital or developmental defects are not diseases or injuries within the meaning of applicable legislation concerning service connection. 38 C.F.R. §§ 3.303(c), 4.9, 4.127 (2012); see also Winn v. Brown, 8 Vet. App. 510, 516 (1996), and cases cited therein. However, where during service a congenital or developmental defect is subject to a superimposed injury or disease, service connection may be warranted. VAOPGCPREC 82-90 (July 18, 1990). Further, in a 1990 opinion, the VA's General Counsel determined that a congenital or hereditary disease could be service connected if it was shown that the disease was first manifested during active military service. See VAOPGCPREC 67-90 (July 18, 1990), 55 Fed. Reg. 43,253 (Oct. 26, 1990) (finding that diseases of hereditary origin can be considered incurred, rather than aggravated, in service "if their symptomatology did not manifest itself until after entry on duty."). VA's General Counsel stated that the existence of a hereditary disease under 38 C.F.R. § 3.303(c) does not always rebut the presumption of soundness, and that service connection may be granted for hereditary diseases which either first manifest themselves during service or which preexist service and progress at an abnormally high rate during service. Id. The General Counsel stated that the mere genetic or familial predisposition to develop the symptoms, even if the individual was almost certain to develop the condition at some time in his life, did not constitute having the disease. Only when symptomatology and/or an active disease process existed could a claimant be said to have developed the disease. Thus, according to the General Counsel, if a claimant had a congenital or hereditary predisposition to a disability prior to service, but no manifestations, but later manifested the disease during active military service, service connection may be granted. See id. Therefore, even if it is determined during service that a Veteran has a congenital disease, VA cannot simply assume that, because of its congenital nature, the disease must have preexisted service. That is, the presumption of soundness still applies to congenital diseases that are not noted at entry. Quirin v. Shinseki, 22 Vet. App. 390, 396-397 (2009). Since the presumption of soundness at entrance attaches, VA must show by clear and unmistakable evidence that the congenital disease preexisted service and was not aggravated in service. Monroe v. Brown, 4 Vet. App. 513, 515 (1993). Thus, the July 2010 VA examination opinion is inadequate for VA rating purposes to determine whether or not the Veteran's pes planus was a congenital disease or defect. When assessing the probative value of a medical nexus opinion, the Board must consider whether the medical opinion contains "such sufficient information that it does not require it to exercise independent medical judgment." Stefl v. Nicholson, 21 Vet.App. 120, 124-25 (2007) ((citing Colvin v. Derwinski, 1 Vet.App. 171, 175 (1991)). The Court has held that the Board may not rely upon its own unsubstantiated medical opinion. Allday v. Brown, 7 Vet. App. 517 (1995); Godfrey v. Brown, 7 Vet. App. 398 (1995); Traut v. Brown, 6 Vet. App. 495 (1994); Colvin v. Derwinski, 1 Vet. App. 171 (1991). In February 2013, the July 2010 VA examiner reexamined the Veteran and provided a clarifying medical opinion. The Veteran was again diagnosed with bilateral flexible pes planus, bilateral plantar fasciosis, and right hallux rigidus. The examiner observed that these conditions had been discussed on VA examination in 2005 and 2010. The examiner provided clear medical definitions of the diagnosed disorders. Specifically, the examiner described "flat foot," flexible pes planus, as a developmental condition of childhood, which from a medical perspective could be considered to be a congenital condition/defect. The examiner explained that although flexible pes planus is usually defined as an acquired condition of childhood, it is not a disease by any medical definition. The examiner noted, however, that one could consider this to be a disease since it may worsen over time, and may or may not be symptomatic. The actual condition of a flat foot may demonstrate progressive pronation and rigidity overtime. The examiner noted that plantar fasciosis and hallux rigidus are common conditions in the general population, and that those with flexible pes planus and its associated foot pronation are more likely to develop the above conditions. The examiner indicated, as previously stated in the 2010 examination report, plantar fasciosis and flexible pes planus may have been temporarily aggravated by military service but "it was not subject to, or aggravated by, a superimposed disease or injury during service with result in additional disability. Rather any increase in severity clearly and unmistakably was due to natural progression of the disorder." Unfortunately, the Board finds that this opinion is also inadequate for VA rating purposes, as the examiner again characterized the Veteran's pes planus as both a defect and a disease. As noted, in April 2013, the Board sought to obtain VHA medical expert opinion to clarify the matter of whether or not the Veteran's bilateral foot disorders were congenital defects or diseases; and whether, if any were congenital or hereditary diseases, whether they were clearly and unmistakably manifest prior to the Veteran's entry into active service, and if so, if there was clear and unmistakable evidence that there was a permanent increase in the severity of the condition beyond its national progression as a result of service. In May 2013, a VHA podiatrist opined that there was insufficient evidence to establish service connection regarding pedal pathology. The podiatrist was in total agreement with the February 2013 examiner regarding flexible pes planus as a developmental condition of childhood and not a disease. The podiatrist considered flexible pes planus as a congenital defect in regards to VA benefits law. The podiatrist explained that this flexible pes planus deformity was a condition that may be classified as asymptomatic or symptomatic, and that classification of this condition could be performed through clinical and radiographic evaluation. Radiographic evaluation was often times performed on the symptomatic variant. The podiatrist observed that the condition might progress throughout the course of life from an asymptomatic to symptomatic state, and might revert from symptomatic to asymptomatic with the use of physical therapy, custom orthosis (UCBL), Richie bracing, or following surgical intervention. The podiatrist noted that a symptomatic flexible pes planus deformity would often demonstrate excessive pronation and associated findings such as tarsal tunnel syndrome, heel spur syndrome, posterior tibial tendon pathology, forefoot abduction, degenerative joint disease throughout the tarsal and metatarsal joints, equinus deformity, and digital contracture from flexor stabilization. The podiatrist explained that plantar fasciosis was a degenerative condition and was not caused by a single traumatic event. The podiatrist noted that the pes planus deformity might predispose a person to arthritis at the first metatarsophalangeal joint as well as plantar fasciosis with heel spur. The podiatrist indicated that plantar fasciosis responded quite favorably to conservative treatment in most instances, although there was the possibility of episodes of recurrence and remission. The podiatrist also noted that hallux limitus could be caused by trauma, although this was not supported in the medical record. The podiatrist explained that hallux limitus was a progressive deformity, which could lead to ankylosis of the joint. The podiatrist explained that plantar fasciosis and hallux limitus would be considered a disease by VA benefits law. The podiatrist commented on the Veteran's service treatment records, and noted that it was interesting that in 1963, the Veteran's boots were reportedly too tight, but there was no mention of nail trauma, blistering, callus or ecchymosis, which would have been more cogent than a diagnosis of bilateral plantar fasciitis with a right heel spur with recommendation for surgery during a brief exit interview without any documentation. The podiatrist opined that there was insufficient evidence to conclude that incorrect shoe fit would cause an asymptomatic pes planus condition to become symptomatic. The podiatrist noted that the Veteran conceded that he did not complain of foot pain until decades after service, and that his body mass index of 26.6 in 1985 was a more plausible explanation for him seeking treatment for pedal discomfort, which was reported to the Worth Foot Clinic of one month duration at initial presentation. The podiatrist concluded that the Veteran's bilateral pedal pathology was not incurred in or aggravated by active service, nor might they be presumed to have been incurred therein. Therefore, the Board finds that the May 2013 VHA podiatrist's opinion that the Veteran's bilateral pedal pathology was not incurred in or aggravated by service, nor presumed to have been incurred therein is highly persuasive because it provides a clear opinion supported by an accurate factual foundation and a thorough explanation. It is clear that the podiatrist delved into the in-service and post-service clinical record, as it was noted that the Veteran did not complain of nail trauma, blistering, callus or ecchymosis in service, and had a body mass index of 26.6 in 1985 when he was first was treated for foot pain post-service. Although the podiatrist's opinion does not expressly discuss the Veteran's friends' and family's reports of observations of his foot symptoms after service, this omission is nonconsequential for several reasons. First, as a general matter, a medical examiner is not required to comment on every favorable piece of evidence in a claims file. See Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012). Second, for the reasons discussed above, the lay statements failed to indicate observations of a continuity of symptoms, and are found not competent evidence to relate the Veteran's current foot symptoms to his in-service foot symptoms. In any event, the bilateral foot disorders addressed in this decision, to include plantar fasciosis and right foot spur, are not disabilities listed under 38 C.F.R. § 3.309(a). Walker, supra. Also significant, an overall reading of the May 2013 VHA podiatrist's opinion is that plantar fasciosis was a degenerative condition and was not caused by a single traumatic event, and that it responded favorably to conservative treatment in most instances. The podiatrist also found that hallux limitus caused by trauma was not supported in the medical record. Any deficiency in the VA examiner's factual foundation or explanation is consequently immaterial. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (a VA examination report "must be read as a whole" to determine an examiner's rationale); Acevedo v. Shinseki, 25 Vet.App. 286, 293-942012); see also Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Accordingly, the probative value of the VA examiner's opinion is not materially diminished in this respect. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board finds that the May 2013 VHA examination is the most probative evidence of record as it consists of clear conclusions based on a thorough examination of the clinical record and consideration of the Veteran's assertions. Moreover, it directly addresses the central question of causation in this case, and includes a determination that the Veteran's flexible pes planus is a congenital defect, and plantar fasciosis and hallux limitis are diseases. The examiner explained that a symptomatic flexible pes planus deformity would often demonstrate excessive pronation and associated findings. There are no related findings in the Veteran's service treatment records, and it was essentially determined that there was no increase in disability during service. The examiner did not identify a superimposed disease or injury in service which resulted in additional disability to the congenital pes planus. The Veteran's assertion that his ill fitting boots caused foot problems was discounted given the lack of commonly associated findings. Rather, it was suggested that the Veteran did not sustain additional disability in service. The Veteran's foot diseases were acknowledged, but the examiner ultimately concluded that the Veteran's bilateral pedal pathology was not incurred in or aggravated by service. Such a medical opinion, which is factually accurate, fully articulated, and based on sound reasoning, carries significant weight. See Nieves-Rodriguez, 22 Vet. App. at 304. The Board, in its own lay capacity (as with the Veteran), is not otherwise qualified to call into question the VA examiner's medical judgment, nor does the Board find any reason to do so. See, e.g., Monzingo, 26 Vet. App. 97, 106 (2012). Accordingly, the Board finds that the VHA opinion, which represents the most probative evidence on this question, establishes that it is less likely than not that a causal relationship ("nexus") between any present bilateral foot disorders and the in-service foot treatment and/or the flexible pes planus congenital defect. Moreover, as noted, the record shows the Veteran was first treated for a foot-related problem in September 1985, nearly two decades after his separation from service, and by his own admission he did not seek treatment for his feet prior to that time because he was just happy to be out and nothing seemed to bother [him] that much..." The passage of so many years between his service separation and the medical documentation of the current bilateral foot disorders is evidence against the claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board finds the evidence against the claim to be more probative than the evidence in favor of the claim. Therefore, the Veteran's claim for service connection for bilateral foot disorders must be 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 in not applicable where, as here, the preponderance of the evidence is against the claim. See 38 U.S.C.A. § 5107(b); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). ORDER Service connection for bilateral foot disorders is denied. ____________________________________________ K. PARAKKAL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs