Citation Nr: 1330860 Decision Date: 09/25/13 Archive Date: 09/30/13 DOCKET NO. 05-10 515 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for a bilateral knee disorder, to include as secondary to service-connected posttraumatic stress disorder (PTSD) and/or low back strain. 2. Entitlement to service connection for a bilateral foot disorder, to include as secondary to service-connected PTSD and/or low back strain. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD L. Edwards, Associate Counsel INTRODUCTION The Veteran had active service from July 1980 to February 1993, including service in the Southwest Asia Theater of operations from December 1990 to February 1992. His awards include a Combat Action Ribbon. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a June 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. A notice of disagreement was received in August 2004, a statement of the case was issued in January 2005, and a VA Form 9 was received in February 2005. In December 2008, the Board remanded these claims for a VA examination and to obtain a nexus opinion. In April 2012, the Board remanded these claims to obtain a nexus opinion regarding secondary service connection. In December 2012, the Board remanded these claims to obtain additional nexus opinions, which were received in January 2013 and clarified in April 2013. The Board is satisfied that there has been substantial compliance with prior remand. See Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (indicating that a Court or Board remand confers upon the Appellant the right to substantial, but not strict, compliance with that order.). That development having been completed, the claims are now partially ready for appellate review. FINDINGS OF FACT 1. A bilateral knee disorder is not causally or etiologically related to service and is not proximately due to or aggravated by service-connected PTSD and/or a low back strain. 2. A bilateral foot disorder is not causally or etiologically related to service and is not proximately due to or aggravated by service-connected PTSD and/or a low back strain. CONCLUSION OF LAW 1. Service connection for a bilateral knee disorder is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). 2. Service connection for a bilateral foot disorder is not established. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist As set forth in the Veterans Claims Assistance Act of 2000 (VCAA), the Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002). Under the VCAA, when VA receives a claim, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim; that VA will seeks to provide; and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). This notice must be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice requirements of the VCAA apply to all five elements of a service-connection claim, including: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. Id. at 486. In the present case, the VCAA duty to notify was satisfied by a letter sent to the Veteran in June 2003 that fully addressed the entire notice element. The letters informed him of what evidence was required to substantiate his claims and of his and the VA's respective duties for obtaining evidence. Additional letters were sent in April 2005 and December 2008. The Veteran's claims were subsequently adjudicated in an April 2013 Supplemental Statement of the Case (SSOC). There is no allegation from the Veteran that he has any evidence in his possession that is needed for full and fair adjudication of this claim, and the Board finds that the notification requirements of the VCAA have been satisfied as to timing and content. To fulfill Dingess requirements, in December 2008, the RO provided the Veteran with notice as to what type of information and evidence was needed to establish a disability rating and the possible effective date of the benefits. Therefore, adequate notice was provided to the Veteran prior to the transfer and certification of his case to the Board and complied with the requirements of 38 U.S.C. § 5103(a) and 38 C.F.R. § 3.159(b). Additionally, VA has a duty to assist the Veteran in claim development. This includes assisting in the procurement of service treatment records and other pertinent medical records, as well as providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. In this case, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Board has obtained VA outpatient, private and service treatment records. Virtual VA records were reviewed. Additionally, multiple VA examinations and opinions were obtained. Therefore, the available medical evidence and records have been obtained in order to make an adequate determination. Neither the Veteran nor his representative has identified any additional existing evidence that has not been obtained or is necessary for a fair adjudication of the claim. The VA's duty to assist in the development of the claim is complete, and no further notice or assistance to the Veteran is required to fulfill the duty. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001). II. Service Connection Claims The Veteran seeks entitlement to service connection for a bilateral knee disorder and a bilateral foot disorder. The Veteran has asserted his disorders are due to an undiagnosed illness. The Persian Gulf War presumption of service connection does not apply if symptoms are medically attributed to a diagnosed (rather than an undiagnosed) illness. See VAOPGCPREC 8-98 (Aug. 3, 1998), 63 Fed. Reg. 56703 (1998); see also Neumann v. West, 14 Vet. App. 12, 22-23 (2000). As the Veteran's claimed disorders are all attributed to diagnosed disorders, the presumptions of service connection for the Gulf War are not applicable. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claims. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that 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). Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage, 10 Vet. App. 488, 495-97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). With chronic diseases shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however, remote, are service connected, unless clearly attributable to intercurrent causes. For a 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. When the disease entity is established, there is no requirement of evidentiary showing of continuity. If the condition noted during service (or in the presumptive period) is not shown to be chronic or where the diagnosis of chronicity may be legitimately questioned, then generally a showing of continuity of symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b). In Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013), the Federal Circuit recently limited the applicability of the theory of continuity of symptomatology in service connection claims to those disabilities explicitly recognized as "chronic diseases" in 38 C.F.R. § 3.309(a). Because arthritis is specifically listed as chronic diseases under 38 C.F.R. § 3.309(a), the theory of continuity of symptomatology is for application in the Veteran's claims of service connection. Secondary service connection may be established when there is causation or aggravation of a Veteran's non-service connected condition that is proximately due to or the result of a service-connected condition. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 448 (1995); Tobin v. Derwinski, 2 Vet. App. 34, 39 (1991). Establishing service connection on a secondary basis requires evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To do so, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Appellant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. In some cases, lay evidence will also be competent and credible on the issues of diagnosis and etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Specifically, lay evidence may be competent and sufficient to establish a diagnosis where (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 at 1377; see also Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009. A layperson is competent to identify a medical condition where the condition may be diagnosed by its unique and readily identifiable features. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App 370, 374 (2002). When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). A. Entitlement to Service Connection for a Bilateral Knee Disorder, to include as secondary to Service-Connected PTSD and/or Low Back Strain The Veteran asserts that his bilateral knee disorder is due to his service-connected PTSD, or in the alternative, is due to his low back strain. Service connection is in effect for PTSD, evaluated as 100 percent disabling, and for low back strain with degenerative changes, evaluated as 20 percent disabling. Service records were reviewed. The Veteran's enlistment examination from June 1980 did not note any knee disorders. Throughout the Veteran's time in service, there were no complaints, treatment, or diagnoses of knee disorders. During reenlistment examinations in April 1986, February 1988, May 1988, and December 1989, there were no noted knee disorders. Post-service records were reviewed. VA outpatient records from June 2002 indicate the Veteran complained of chronic knee pain. He was prescribed Naproxen and Glucosamine. In August 2002, the Veteran complained of left knee pain since 1993, which was progressively worse. He was diagnosed with minor degenerative joint disease of the knee. In December 2002, he was diagnosed with osteoarthritis of the bilateral knees. In June 2003, the Veteran had crepitus in both knees. In September 2003, the Veteran had a Persian Gulf Exam, where he reported left knee pain that he had prior to the Gulf War conflict. In November 2003, he again complained of knee pain. The Veteran was afforded a VA examination in May 2004. He reported bilateral knee joint pain since 1989, which he attributed to running during military service. It was noted that he did not seek medical attention during service because the pain was not too bad. He was scheduled for a knee x-ray in June 2003, but he did not show up. The examiner stated that from the history and examination, his knee pain is more likely patellofemoral syndrome, or runner's knee. X-rays were ordered, and demonstrated no evidence of degenerative changes. In November 2004, the Veteran again complained of knee pain, and was instructed to continue on Naproxyn. The Veteran was afforded a VA examination in October 2009. The Veteran reported gradual knee pain that began during Desert Storm, but that he did not seek medical treatment during service. Examination revealed that the Veteran's gait was abnormal due to problems with his feet. The Veteran was diagnosed with bilateral patellofemoral syndrome. The examiner opined that it is less likely than not that the Veteran's bilateral knee disorders were related to his military service as there was no evidence in the medical record that his had knee problems during service and the Veteran had no complaints or findings for knee problems during any of the physical examinations during service. An addendum opinion was obtained in April 2011. The examiner opined that it is less likely than not that the Veteran's current knee disorder had its onset during his time in active duty. The examiner noted that notwithstanding the Veteran's lay reports of knee pain, there was no evidence in the service treatment records. The examiner stated that it is more likely that the Veteran would have by necessity sought medical attention during the time period in question due to the degree of associated symptoms, which would have been documented in the records. The examiner noted that although it is understandable that the Veteran might perceive that his history of running and carrying heavy backpacks during his time in service subsequently resulted in his current knee problems, his allegations as to when these conditions began are simply not supported by the objective nature of the records. The Veteran submitted an article regarding PTSD and Physical Health, which indicated that people with PTSD are more likely to experience a number of physical health problems, including arthritis. A VA medical opinion was obtained in May 2012 from a psychologist. The examiner stated that the article submitted was reviewed, but a review of current medical literature did not reveal any articles that definitely linked PTSD with knee problems. As such, the examiner opined that it is less likely than not that the Veteran's PTSD aggravates his knee disorders. The Veteran was afforded a VA examination in January 2013. X-rays demonstrated mild degenerative changes. The examiner opined that it is less likely than not that the Veteran's bilateral knee disorder was caused by his lower back disorder. The examiner noted that the predominance of medical literature does not support that bilateral knee disorders are caused by lower back disorders. The examiner also opined that it is not at least as likely as not that the Veteran's low back disorder aggravated his bilateral knee disorder as the medical literature does not support that a knee disorder is aggravated by a low back strain. The examiner clarified the January 2013 opinions in April 2013. The examiner opined that the Veteran's bilateral knee disorder are less likely than not aggravated by his back strain and is more likely attributed to advanced age, previous injury, sports activities, genetic elements, occupation, muscle weakness, calcium crystal deposition disease, or other bone or joint disorder. The Veteran's lay statements in support of his claim have been considered, as well as those of his sister. The Board notes that the Veteran is competent to comment on any symptoms, such as pain. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). ). However, although laypersons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case involving orthopedic disorders, falls outside the realm of common knowledge of a layperson. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). To date, there is no medical evidence demonstrating a causal relationship between the Veteran's time in service and his currently diagnosed bilateral knee disorder. Additionally, there is no medical evidence demonstrating a causal relationship between the Veteran's bilateral knee disorder and his service-connected PTSD or low back strain. Because of the absence of a medical nexus, the Board finds that the evidence is against a grant of service connection. Although there has been continual treatment of knee disorders post service, importantly, there were no noted knee disorders during service and all of the VA examiners have opined that the Veteran's bilateral knee disorder is not due to service and is not proximately due to or aggravated by his service-connected PTSD and/or low back strain. Although the Veteran submitted an article indicating that people with PTSD are more likely to experience a number of physical health problems, including arthritis, there is no evidence that indicates the Veteran's particular knee problem is associated with PTSD. The evidence of record fails to demonstrate that the Veteran was diagnosed or treated for knee problems during service or that any current residuals can be related to his time in service. To date, there is no probative evidence of record that relates any current knee disorder to his time in service or to any service-connected disability. In summary, the weight of the evidence reflects that the Veteran did not develop a bilateral knee disorder until after service. There were no symptoms or diagnosis of a bilateral knee disorder during service. As such, service connection may not be granted on a presumptive basis for chronic disability. See 38 C.F.R. §§ 3.307(a)(3), 3.309(a). There is no evidence of continuity of symptomatology as a knee disorder was not specifically noted in service and was not noted in post-service treatment records until many years after service. Furthermore, multiple VA examiners have opined that the Veteran's current bilateral knee disorder is less likely than not due to service and is less likely than not proximately due to or aggravated by his service-connected PTSD and/or low back strain. Consequently, the Board finds that the preponderance of the evidence is against entitlement to service connection for a bilateral knee disorder. As the preponderance of the evidence is against his claim, the doctrine of reasonable doubt is not for application. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the appeal is denied. B. Entitlement to Service Connection for a Bilateral Foot Disorder, to include as secondary to Service-Connected PTSD and/or Low Back Strain The Veteran asserts that his bilateral foot disorder is due to service, or in the alternative, is due to his PTSD and/or low back strain. Service records were reviewed. The Veteran's enlistment examination from June 1980 did not note any foot disorders. Throughout the Veteran's time in service, there were no complaints, treatment, or diagnoses of foot disorders. During reenlistment examinations in April 1986, February 1988, May 1988, and December 1989, there were no noted foot disorders. Post-service records were reviewed. The Veteran submitted a statement in May 1996 indicating that he had calluses on his feet, but that he self-treated them by shaving them with a razor. In October 2002, he also stated that his foot pain began during service and that he believes his calluses are due to his time in service. In September 2003, the Veteran had a Persian Gulf Exam, where he reported foot pain during and since the Gulf War. The Veteran was afforded a VA examination in May 2004. He reported foot pain, which was aggravated by jogging. Examination revealed a normal gait, but there were scaly lesions on the plantar aspect of both feet. It was noted that the Veteran avoided running or jogging. Examination of the feet revealed tenderness at the medial arch close to the heel and MP joint of the great toe area. The examiner stated the pain appeared to be plantar fasciitis, and hallux valgus. The great toe also had a mild bunion condition. The examiner stated there were no callus, and no unusual shoe-wear pattern. The Veteran was diagnosed with hallux valgus, bilateral, mild bunions, bilateral, and plantar fasciitis, bilateral. X-rays demonstrated bilateral tiny posterior calcaneal spurs, but no significant degenerative changes. The Veteran was afforded a VA examination in October 2009. The Veteran reported doing a lot of walking in service and that he started to get calluses on the bottom of his feet. He reported they were so bad that he shaved them every few days. Examination revealed tenderness at the site of calluses, but no tenderness along the plantar facia, bilaterally. The Veteran was diagnosed with bilateral hallux valgus deformity, bunion, and plantar fasciitis. The examiner opined that the Veteran's bilateral foot disorder was less likely as not related to service as there was no evidence in the medical records that the Veteran had problems with his feet during service. The examiner stated there were no visits for medical treatment for any of the currently diagnosed disorders during service and no report or findings of the current foot disorders on any of the physical examinations during service. An addendum opinion was obtained in April 2011. The examiner opined that notwithstanding the fact that the Veteran suffered from foot problems during his time in service, there remains no evidence in the service treatment records in support of a foot disorder. The examiner noted that the initial report of foot problems, of record, post service, was in 1996, well after the Veteran's separation from service. The examiner opined that it is more likely than not that the Veteran would have by necessity, sought medical attention during the time period in question, due to the degree of associated symptoms. The examiner noted that although it is understandable that the Veteran might perceive that his history of running and carrying heavy backpacks during his time in service subsequently resulted in his current foot problems, his allegations as to when these conditions began are simply not supported by the objective nature of the records. Finally, the examiner noted that many other Veterans were presumably exposed to the same conditions during service and did not develop foot problems; therefore, the Veteran's combat conditions alone cannot be considered as the only factor in the development of his foot problems. The examiner noted that according to the current body of medical literature, there are any number of potential causes of both hallux valgus deformity and plantar fasciitis, but there is no specific singular etiology identified for either. The Veteran submitted an article regarding PTSD and Physical Health, which indicated that people with PTSD are more likely to experience a number of physical health problems, including arthritis. A VA medical opinion was obtained in May 2012 from a psychologist. The examiner stated that the article submitted was reviewed, but a review of current medical literature did not reveal any articles that definitely linked PTSD with foot problems. As such, the examiner opined that it is less likely than not that the Veteran's PTSD aggravates his foot disorders. The Veteran was afforded a VA examination in January 2013. X-rays demonstrated pes planus, hallux valgus with degenerative joint disease and bunion, and possible anterior and posterior impingement syndrome at the tibiotalar joint in the left foot and pes planus and hallux valgus with bunion in the right foot. The examiner opined that it is less likely than not that the Veteran's bilateral foot disorder was caused by his lower back disorder. The examiner noted that the predominance of medical literature does not support that bilateral foot disorders are caused by lower back disorders. The examiner also opined that it is not at least as likely as not that the Veteran's low back disorder aggravated his bilateral foot disorder as the medical literature does not support that a foot disorder is aggravated by a low back strain. The examiner stated the pathophysiology of the Veteran's bilateral foot conditions are not attributable or caused by a back strain. The Veteran's lay statements in support of his claim have been considered, as well as those of his sister. The Board notes that the Veteran is competent to comment on any symptoms, such as pain. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). ). However, although laypersons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case involving orthopedic disorders, falls outside the realm of common knowledge of a layperson. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Furthermore, to date, there is no medical evidence demonstrating a causal relationship between the Veteran's time in service and his currently diagnosed bilateral foot disorder. Additionally, there is no medical evidence demonstrating a causal relationship between the Veteran's bilateral foot disorder and his service-connected PTSD or low back strain. Because of the absence of a medical nexus, the Board finds that the evidence is against a grant of service connection. Importantly, all of the VA examiners have opined that the Veteran's bilateral foot disorder is not due to service and is not proximately due to or aggravated by his service-connected PTSD and/or low back strain. Although the Veteran submitted an article indicating that people with PTSD are more likely to experience a number of physical health problems, including arthritis, there is no evidence that indicates the Veteran's particular foot problem is associated with PTSD. The evidence of record fails to demonstrate that the Veteran was diagnosed or treated for foot problems during service or that any current residuals can be related to his time in service. To date, there is no probative evidence of record that relates any current foot disorder to his time in service. In summary, the weight of the evidence reflects that the Veteran did not develop a bilateral foot disorder until after service. There were no symptoms or diagnosis of a bilateral foot disorder during service. As such, service connection may not be granted on a presumptive basis for chronic disability. See 38 C.F.R. §§ 3.307(a)(3), 3.309(a). There is no evidence of continuity of symptomatology as a foot disorder was not specifically noted in service and was not noted in post-service treatment records until many years after service. Furthermore, multiple VA examiners have opined that the Veteran's current bilateral foot disorder is less likely than not due to service and is less likely than not proximately due to or aggravated by his service-connected PTSD and/or low back strain. Consequently, the Board finds that the preponderance of the evidence is against entitlement to service connection for a bilateral foot disorder. As the preponderance of the evidence is against his claim, the doctrine of reasonable doubt is not for application. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Accordingly, the appeal is denied. ORDER Entitlement to service connection for a bilateral knee disorder, to include as secondary to service-connected PTSD and/or low back strain is denied. Entitlement to service connection for a bilateral foot disorder, to include as secondary to service-connected PTSD and/or low back strain is denied. ____________________________________________ WAYNE M. BRAEUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs