Citation Nr: 1329388 Decision Date: 09/13/13 Archive Date: 09/20/13 DOCKET NO. 10-12 817 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUE Entitlement to service connection for a right foot/ankle disability. REPRESENTATION Veteran represented by: Oregon Department of Veterans' Affairs WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD E. Pomeranz, Counsel INTRODUCTION The Veteran had active service from August 1970 to September 1973. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a March 2009 rating action by the Department of Veterans Affairs (VA) Regional Office (RO) located in Portland, Oregon. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ) in June 2013. A copy of the transcript of that hearing is of record. After the Travel Board hearing, the VLJ left the record open for 30 days to allow the Veteran to submit additional evidence. In July 2013, the Veteran submitted private medical records dated in August 1980 that were pertinent to his claim. He waived the right to have the evidence initially considered by the RO. 38 C.F.R. § 20.1304(c). FINDINGS OF FACT 1. There is no competent evidence of record showing a current diagnosis of a right foot disability. 2. A right ankle disability, to include degenerative arthritis of the right ankle, was not manifest during active service, arthritis was not manifest within the first post- service year, and a right ankle disability, to include degenerative arthritis of the right ankle, is not shown to have developed as a result of an established event, injury, or disease during active service. CONCLUSION OF LAW Entitlement to service connection for a right foot/ankle disability, to include degenerative arthritis of the right ankle, is not warranted. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA enhanced VA's duty to notify a claimant as to the information and evidence necessary to substantiate 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, 3.326(a) (2012). The VCAA also redefined the obligations of VA with respect to the duty to assist the veteran with the claim. Id. In the instant case, the Board finds that VA fulfilled its duties to the Veteran under the VCAA. Duty to Notify VA has a duty to notify the veteran of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. In order to meet the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must: (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). Additionally, on March 3, 2006, the United States Court of Appeals for Veterans' Claims (Court) issued a decision in Dingess v. Nicholson, 19 Vet. App. 473, 484, 486 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (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. The Board finds that VA has met these duties with regard to the claim adjudicated on the merits in this decision. There is no issue as to providing an appropriate application form or completeness of the application. Written notice provided in July 2008 fulfills the provisions of 38 U.S.C.A. § 5103(a). That is, the Veteran received notice of the evidence needed to substantiate his claim, the avenues by which he might obtain such evidence, and the allocation of responsibilities between himself and VA in obtaining such evidence. See Beverly, 19 Vet. App. at 394, 403; see also Mayfield v. Nicholson, 19 Vet. App. 103, 109-12 (2005) (Mayfield I) rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). In addition, the July 2008 letter also informed the Veteran about how VA determines effective dates and disability ratings, as required by Dingess. The Board also recognizes that, according to Pelegrini v. Principi, 18 Vet. App. 112, 119-20 (2004), proper VCAA notice must "precede an initial unfavorable [agency of original jurisdiction (AOJ)] decision on a service- connection claim." VA did provide such notice to the Veteran prior to the March 2009 decision that is the subject of this appeal in its July 2008 letter. With respect to the Dingess requirements, the Veteran was provided with notice of what type of information and evidence was needed to substantiate the claim, as well as the type of evidence necessary to establish a rating or effective date of an award (see letter from RO, dated in July 2008), and such notice was provided prior to the initial decision of the RO. See Dingess, supra. Accordingly, the RO provided proper VCAA notice at the required time. The Veteran has been provided the opportunity to respond to VA correspondence and over the course of the appeal has had multiple opportunities to submit and identify evidence. Furthermore, he has been provided a meaningful opportunity to participate effectively in the processing of his claim by VA. Duty to Assist VA also has a duty to assist the veteran in obtaining evidence necessary to substantiate the claim. 38 U.S.C.A. § 5103A(a) ("The Secretary shall make reasonable efforts to assist a claimant in obtaining evidence necessary to substantiate the . . . claim"). This duty includes assisting the veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). VA informed the Veteran of its duty to assist in obtaining records and supportive evidence, and the Veteran received a VA examination in January 2013 which was thorough in nature and adequate for the purposes of deciding this claim. In the examination report, the examiner stated that the Veteran's right foot was normal. In addition, he diagnosed the Veteran with degenerative arthritis of the right ankle and opined that such right ankle disability was not related to the Veteran's period of active service; rather, he linked the Veteran's right ankle disability to his 30-year employment as a baker where he had to stand for long hours. The examiner noted that the Veteran also had degenerative arthritis in his left ankle and that such bilateral arthritis was consistent with work as a cause. The examiner's opinion was supported by adequate rationale and is deemed sufficient for the purpose of this adjudication. VA has no further duty to provide an examination or medical opinion. 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159 (c ) (4) (2012). See also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran was afforded a Travel Board hearing before the undersigned VLJ in June 2013, in which he presented oral argument. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) (2012) requires that the VLJ/DRO who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, the undersigned VLJ set forth the issue to be discussed at the hearing and sought to identify any pertinent evidence not currently associated with the claims folder that might have been overlooked or was outstanding that might substantiate the claims. In this regard, the Veteran testified that after his discharge, he did not seek any treatment for his right foot/ankle disability until approximately 2011 when he sought treatment at the VA Medical Center (VAMC) in Portland. The Board notes that the evidence of record is negative for any outpatient treatment records from the Portland VAMC. However, in the January 2013 VA examination report, the examiner stated that the Veteran was seen at the Portland VAMC for his ankles and that x-rays taken at that time were reported to show mild degenerative changes, bilaterally. Thus, the Board acknowledges that the VAMC records show current treatment for the Veteran's right ankle disability. In addition, the Board notes that the Veteran has not alleged that the VAMC records show anything other than such treatment. Therefore, the failure to obtain these records is harmless error. In the June 2013 Travel Board hearing, the VLJ notified the Veteran that in order to prove his claim he had to show that he currently had a right foot and/or ankle disability that was related to his active service. The record was left open so that the Veteran could submit private treatment records dated in 1980. Moreover, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. 3.103(c)(2), nor have they identified any prejudice in the conduct of the Board hearing. The hearing focused on the elements necessary to substantiate the claim and the Veteran, through his testimony, demonstrated that he had actual knowledge of those elements. As such, the Board finds that consistent with Bryant, the VLJ complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board can adjudicate the claims based on the current record Based on the foregoing, it is the Board's determination that the VA fulfilled its VCAA duties to notify and to assist the Veteran, and thus, no additional assistance or notification was required. The Veteran has suffered no prejudice that would warrant a remand, and his procedural rights have not been abridged. See Bernard, supra. II. Pertinent Laws and Regulations Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when the evidence, including that pertinent to service, establishes the disease was incurred in service. 38 C.F.R. § 3.303(d). In interpreting sections 1110 and 1131 of the statute and section 3.303(a) of the regulations, the Federal Circuit Court held that a three-element test must be satisfied in order to establish entitlement to service connection. Specifically, the evidence must show (1) the existence of a current disability; (2) in-service incurrence or aggravation of a relevant disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the "nexus" requirement). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (citing Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004))). Under 38 C.F.R. § 3.303(b), claims for certain chronic diseases-namely those listed in 38 C.F.R. § 3.309(a)-benefit from a somewhat more relaxed evidentiary standard. See Walker, supra (holding that "[t]he clear purpose of the regulation is to relax the requirements of § 3.303(a) for establishing service connection for certain chronic diseases."). When a chronic disease is established during active service, then subsequent manifestations of the same chronic disease at any later date, however remote, will be entitled to service connection, unless clearly attributable to causes unrelated to service ("intercurrent causes"). 38 C.F.R. § 3.303(b). In order to establish the existence of a chronic disease in service, the evidence must show a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Id. Thus, the mere manifestation during service of potentially relevant symptoms (such as joint pain or abnormal heart action in claims for arthritis or heart disease, for example) does not establish a chronic disease at that time unless the identity of the disease is established and its chronicity may not be legitimately questioned. Id. If chronicity in service is not established, then a showing of continuity of symptoms after discharge is required to support the claim. Id. The Federal Circuit noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a veteran can establish service connection for a chronic disease" under subsection 3.303(b). Walker, supra. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation"). Significantly, the Federal Circuit indicated that showing a continuity of symptomatology after service is a lesser evidentiary burden than the nexus requirement of the three-part test discussed above: "The primary difference between a chronic disease that qualifies for § 3.303(b) analysis, and one that must be tested under § 3.303(a), is that the latter must satisfy the 'nexus' requirement of the three-element test, whereas the former benefits from presumptive service connection . . . or service connection via continuity of symptomatology" (emphasis added). Id. Not all diseases that may be considered "chronic" from a medical standpoint qualify for the relaxed evidentiary standard under section 3.303(b). Rather, the Federal Circuit held that this subsection only applies to the specific chronic diseases listed in 38 C.F.R. § 3.309(a). Id. Thus, if the claimant does not have one of the chronic diseases enumerated in section 3.309(a), then the more relaxed continuity-of-symptomatology standard does not apply, and "medical nexus of a relationship [sic] between the condition in service and the present condition is required." Walker, supra. (holding that the claimant's allegation of a continuity of hearing loss ever since active service was not sufficient to support the claim under subsection 3.303(b), as hearing loss was not among the chronic diseases listed in section 3.309(a)). The evidence of record is negative for a current diagnosis of a right foot disability. However, the evidence shows that the Veteran has a current right ankle disability, diagnosed as degenerative arthritis of the right ankle. Arthritis is defined as a chronic disease in section 3.309(a). Thus, the provisions of subsection 3.303(b) for chronic disabilities apply to this aspect of the service connection claim and the claim may be supported by evidence of a continuity of symptomatology after service. Arthritis is also eligible for presumptive service connection. Specifically, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, service connection for arthritis may be established on a presumptive basis by showing that the 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. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307; 3.309(a). However, this presumption will be rebutted if there is affirmative evidence to the contrary. 38 C.F.R. § 3.307(d). Lay evidence nonetheless can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (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). Lay persons can also provide an eye-witness account of an individual's visible symptoms. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that a layperson may comment on lay-observable symptoms). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The standard of proof to be applied in decisions on claims for veterans' benefits is set forth in 38 U.S.C.A. § 5107. A veteran is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence. See also 38 C.F.R. § 3.102. When a veteran seeks benefits and the evidence is in relative equipoise, the veteran prevails. See Gilbert, 1 Vet. App. at 49. The preponderance of the evidence must be against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996). III. Factual Background The Veteran's service treatment records are negative for any complaints or findings of a right foot disability and/or injury. However, the records do show that in May 1972, the Veteran was treated at Camp Pendleton for a sprained right ankle. It was noted that the Veteran had recently fallen. X-rays of the right ankle were reported to be negative. The Veteran was given an ace wrap. The remaining records are negative for any complaints or findings of a right ankle disability and/or injury. In August 1973, the Veteran underwent a separation examination. At that time, his feet and lower extremities were clinically evaluated as "normal." Private medical records show that in August 1980, the Veteran slipped and fell. He sought treatment and was diagnosed with a fracture of the proximal 5th metatarsal of the right foot. HE stated that he had no prior problems. In June 2008, the Veteran filed his initial claim for service connection for a right foot disability. Specifically, he noted that he had a "right foot condition with painful motion and arthritis." In a VA Form 21-4142, Authorization and Consent to Release Information to the VA, dated in October 2008, the Veteran stated that in August 1972, he had "dislocated [his] right foot" while he was performing field maneuvers and was "off loading" from a CH- 46 helicopter. According to the Veteran, he received treatment at Camp Pendleton. Private medical records show that in April 2010, the Veteran underwent an outpatient podiatry consultation for ankle pain. At that time, he stated that during service, he dislocated and "broke" his ankle. The Veteran indicated that at present, he had pain in his right ankle. The physical examination showed that the Veteran had mild edema of the right ankle with no neurological deficits noted. There were no specific areas of pain or discoloration. Range of motion was fluid. There was a small click with forced end range plantar flexion which did not cause pain. There was no crepitation. The Veteran had slight reduction in dorsiflexion and plantar flexion. There was mild instability. The impression was of an old ankle injury, possible subluxation, doubt dislocation but possible. At the time of the examination, x-rays were taken of the Veteran's ankles. The x-rays were interpreted as showing degenerative changes of the ankles, bilaterally. In January 2013, the Veteran underwent a VA examination. At that time, the examiner stated he had reviewed the Veteran's claims file. The examiner indicated that during service, the Veteran was treated for a right ankle sprain. The Veteran was treated with rest and returned to normal duty. He had no treatment since that time and had a variety of jobs after service until 1981, when he became a baker which required standing for long hours on a daily basis. At present, the Veteran had no loss of function and no symptoms. He denied locking, clicking, popping, or any loss of motion or strength. The Veteran experienced flare-ups with heavy lifting, carrying, and twisting that caused general ankle ache. He injured his right foot in 1980 when he fractured his fifth metatarsal and was treated with a cast and had a complete recovery without any symptoms. The Veteran was treated at the VAMC for his bilateral ankles two years prior and x-rays showed that he had mild degenerative changes, bilaterally. Following the physical examination, the examiner diagnosed the Veteran with a normal right foot and with degenerative changes of the right ankle. The examiner noted that the Veteran also had degenerative changes of the left ankle. He opined that the Veteran's currently diagnosed bilateral degenerative changes of the ankles were consistent with his work for standing long hours baking for 30 plus years. According to the examiner, it was not at least as likely as not that the Veteran's "right foot" was "service-connected" as there was no nexus without treatment for 30 plus years. [Although the examiner stated "right foot," it is clear from the context of his statements that he was referring to the Veteran's right ankle.] The examiner noted that the Veteran's degenerative changes were bilateral and therefore consistent with work as the cause. In the June 2013 Travel Board hearing, when the Veteran's representative asked him to describe how he injured his right "ankle" during service, he then described a right "foot" injury that occurred in the barracks while he was performing "defensive moves." According to the Veteran, two days after he injured his right foot, he re-injured the foot when he was going up a "dry stream bed" and his foot went out like a "trick foot." The Veteran indicated that he experienced pain in his right foot for approximately two and a half months before the pain subsided. He noted that after his discharge, he experienced flare-ups of pain in his right foot. According to the Veteran, after his discharge, he did not seek any treatment for right foot/ankle problems until 2011. IV. Analysis Based on a thorough review of the record, the Board finds that there is a preponderance of evidence against the Veteran's claim for service connection for a right foot/ankle disability, to include degenerative arthritis of the right ankle. In this case, the Veteran's service treatment records show that in May 1972, he sprained his right ankle. Thus, the records document that he injured his right ankle while he was in the military. However, the records are negative for any evidence showing that he injured his right foot during service. Nevertheless, it appears that it is the Veteran's contention that when he injured his right ankle, he also injured his right foot. The Veteran is competent under the law to describe what he experienced while in military service. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Regardless, even if the Board accepts as true that he injured his right foot when he injured his right ankle, it is apparent that whatever manifestations of the right foot injury that were present during service were acute and transitory and resolved with no residual disability given the normal separation examination. In the August 1973 separation examination report, the Veteran's feet were clinically evaluated as "normal." Service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In the instant case, there is no competent evidence showing a current diagnosis of a right foot disability. In the January 2013 VA examination report, the examiner stated that the Veteran's right foot was normal. The only evidence of record supporting the Veteran's claim is his own lay opinion that he currently has a right foot disorder. He has reported that he currently has pain in his right foot. The Veteran is certainly competent to testify as to symptoms such as pain in his right foot. However, a symptom, such as pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). In this case, no underlying right foot disability has been diagnosed. While the Veteran is competent to give evidence about observable symptoms such as experiencing pain in his right foot, he is not competent to give an opinion as to whether he has a right foot disability as this issue involves highly complex medical questions. Determining the etiology of complex medical conditions requires medical training and would not be subject to lay observation, as contrasted with the situations contemplated by Jandreau and Barr. Here, the Veteran's lay opinion that he has a right foot disability is not competent evidence and lacks probative value. Nevertheless, the evidence of record does show that the Veteran currently has a right ankle disability, diagnosed as degenerative arthritis of the right ankle. In this regard, the Board observes that arthritis is diagnosed on the basis of clinical and x-ray examinations. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (2012) (degenerative arthritis must be confirmed by x-ray to qualify as a ratable entity). Given that arthritis must be objectively confirmed by x-ray, the Board notes that although the Veteran injured his right ankle during service and subsequently developed pain in his right ankle, no underlying disability was diagnosed, i.e., there is no objective x-ray documentation of arthritis of the right ankle during the Veteran's period of active service. In fact, x-rays taken at the time of his right ankle injury were negative. Thus, to the extent that the Veteran experienced right ankle pain during service, the Board observes that a symptom, such as pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted. Sanchez-Benitez, supra. The Board recognizes that the Veteran's service treatment records show that the Veteran sprained his right ankle in May 1972. However, the remaining records are negative for any complaints or findings of a right ankle disability and/or injury. In fact, at the time of the Veteran's August 1973 separation examination, the Veteran's lower extremities were clinically evaluated as "normal." The first x-ray evidence of a right ankle disability is in April 2010, over 36 years after the Veteran's discharge. Private medical records show that in April 2010, x-r-rays of the Veteran's right ankle were reported to show degenerative changes. With respect to negative evidence, the Court has held that the fact that there was no record of any complaint, let alone treatment, involving the veteran's condition for many years could be decisive. See Maxson v. West, 12 Vet. App. 453, 459 (1999), affirmed sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000), [it was proper to consider the veteran's entire medical history, including a lengthy period of absence of complaints]. The Board also notes that, as there is no medical evidence of arthritis of the right ankle within one year subsequent to service discharge, the presumptive provisions for this disease found in 38 C.F.R. §§ 3.307 and 3.309 are not applicable. The Board recognizes that the Veteran has a current right ankle disability, diagnosed as degenerative arthritis of the right ankle. However, there is no competent and credible evidence of record of a nexus between the Veteran's currently diagnosed right ankle disability and any incident of service, to include his in-service right ankle sprain. In this case, the only competent medical opinion that addresses the contended causal relationship is from the VA clinician who examined the Veteran in January 2013, and his opinion weighs against the claim. In the January 2013 VA examination report, the examiner opined that the Veteran's currently diagnosed degenerative arthritis of the right ankle was not related to his period of active service. Rather, the examiner linked the Veteran's right ankle disability to his 30-year history of working as a baker and standing for long periods of time. The examiner noted that because the Veteran had arthritis in both ankles, that was consistent with work as the cause of the arthritis. This opinion opposes, rather than supports, the claim. The Board notes that in the private medical records, dated in April 2010, although the examiner stated that the Veteran had an old ankle injury, he did not address the pertinent nexus question of whether the Veteran's currently diagnosed degenerative arthritis of the right ankle was related to his period of active service, specifically his in-service right ankle sprain. Thus, this evidence neither supports or opposes the claim. The only evidence supporting the Veteran's claim is his own lay evidence that he has a right ankle disability, currently diagnosed as degenerative arthritis of the right ankle, that is related to his period of service, specifically to his in- service right ankle sprain. The Board acknowledges Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007), in which it was held a lay person may speak as to etiology in some limited circumstances in which nexus is obvious merely through lay observation, such as a fall leading to a broken leg. The Veteran is certainly competent to testify as to symptoms such as right ankle pain. Here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship. The Veteran is not competent in this instance to opine that his right ankle arthritis is related to his service, specifically to his in- service right ankle sprain, because that is a complex medical question that requires medical expertise and training. Specifically, degenerative arthritis is diagnosed on the basis of clinical and x-ray examinations. Specialized education and/or training are required for a determination as to such diagnosis or to determine the etiology of arthritis. Here, the Veteran has no such training or credentials. Absent such credentials, the Veteran is unable to provide a competent opinion as to medical causation. See 38 C.F.R. § 1.59(a)(2). As a consequence, the Veteran's lay opinion would be of no more than minimal probative value, and is very substantially outweighed by the January 2013 opinion from the VA examiner because the examiner is a qualified medical professional who has the clear expertise to opine on the matter at issue in this case. As for continuity of symptomatology since service, it is within the Veteran's realm of personal knowledge that he experienced pain in his right ankle during service and following his discharge. However, even if deemed credible, it does not follow that any present right ankle disability is necessarily related to any demonstrated continuous symptomatology. While the Veteran is competent to state that he has experienced right ankle symptomatology since service, he is not competent to determine the underlying cause of that right ankle pain, i.e., arthritis of the right ankle. As explained above, without the appropriate medical training and expertise, the Veteran is not competent to provide an opinion on a medical matter, such as etiology of his right ankle disability because this requires medical expertise. See Jandreau, supra. Therefore, although the Veteran's statements as to the etiology of his disability have been given full consideration by the Board, they are not considered competent evidence and do not serve to link this disability to service. In light of the above, the Board concludes that there is a preponderance of evidence against the Veteran's claim for service connection for a right foot/ankle disability, to include degenerative arthritis of the right ankle. In reaching this decision, the Board considered the doctrine of reasonable doubt. However, since the preponderance of the evidence is against the claim, the benefit of the doubt doctrine does not apply and the claims must be denied. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001) (holding that "the benefit of the doubt rule is inapplicable when the preponderance of the evidence is found to be against the claimant"); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a right foot/ankle disability, to include degenerative arthritis of the right ankle, is denied. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs