Citation Nr: 1335263 Decision Date: 11/01/13 Archive Date: 11/13/13 DOCKET NO. 06-12 443 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to service connection for a left foot and toe disorder. REPRESENTATION Veteran represented by: Vietnam Veterans of America WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jebby Rasputnis, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1985 to September 1990. He subsequently completed reserve service until August 1992. This appeal was last before the Board of Veterans' Appeals (Board) in March 2013, on appeal from an April 2005 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. Jurisdiction of the claims file has been transferred to the RO in Atlanta, Georgia. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a February 2009 travel hearing at the RO in Atlanta and a transcript of that hearing appears in the claims file. Subsequently, the Board issued a June 2009 Remand in which it noted that, although the Veteran had claimed entitlement to service connection for foot and toe disabilities, generally, he later - in writing and at the hearing - expressed that his claim, after the RO's December 2008 issuance of a rating decision granting service connection for a right ankle disability, was limited to the left side. The Board recharacterized his claim accordingly. See 38 C.F.R. § 19.35 (2013) (certification is used for administrative purposes and does not serve to either confer or deprive the Board of Veterans' Appeals of jurisdiction over an issue.). In March 2010, the Board issued a decision denying the Veteran's claim for service connection for chronic disability of the left foot and toe. The Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court), which, in a June 2010 memorandum decision, vacated the March 2010 Board decision. The Court remanded that issue, service connection for chronic disability of the left foot and toe, to the Board for further development and readjudication. See Chisem v. Gober, 10 Vet. App. 526 (1997). In accordance with the Court's remand, the Board remanded the claim in September 2010 for the provision of a new VA examination. After additional development, to include the provision of an examination, the Appeals Management Center (AMC) returned the appeal to the Board for readjudication. However, the examination results were not sufficient so the Board remanded the appeal again in both October 2011 and March 2013 in order to obtain another medical opinion as well as additional records. The matter has now been returned, again, to the Board for appellate disposition. As discussed below, the Board finds that the AOJ substantially complied with the 2010, 2011, and 2013 remand orders with respect to the claim decided herein; no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In addition to the paper claims file, there is a Virtual VA paperless claims file associated with the Veteran's appeal. The Board has reviewed the additional medical evidence within the Veteran's virtual file. Although the Veteran submitted additional evidence in July 2013, after issuance of the most recent supplemental statement of the case. Review of the claims file reflects that all of that evidence, with the exception of argument and lay statement, was already within the claims file. Regardless, as the Veteran also submitted a waiver of RO consideration, the Board can accept that evidence for purposes of appellate review. 38 C.F.R. § 20.1304 (2013). The issue of entitlement to service connection for migraine headaches was referred to the RO in June 2009. Unfortunately, although this issue has been raised by the record, it still has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it and it is again REFERRED to the AOJ for appropriate action. FINDING OF FACT No left foot, to include toe, disorder is shown to be causally or etiologically related to any disease, injury, or incident during service. CONCLUSION OF LAW A left foot, to include toe, disorder was not incurred in, or aggravated by, the Veteran's active duty military service. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002& Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2013). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b) (1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) 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. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, an October 2004 letter, sent prior to the initial unfavorable rating decision, generally advised the Veteran of the evidence and information necessary to substantiate a claim for service connection as well as his and VA's respective responsibilities in obtaining such evidence and information. Letters sent to the Veteran in June 2006 and March 2008 informed the Veteran of the evidence and information necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. Moreover, the 2008 letter again advised the Veteran of the evidence and information necessary to substantiate a claim for service connection. Although the 2006 and 2008 letters were issued after the initial rating decision, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that VA can cure such a timing problem by readjudicating the Veteran's claim following the issuance of a compliant VCAA notification letter. Mayfield v. Nicholson, 444 F.3d 1328, 1333-34 (Fed. Cir. 2006). The Court clarified that the issuance of a statement of the case could constitute a readjudication. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In the instant case, after the 2006 and 2008 letters were issued, the Veteran's claim was readjudicated in supplemental statements of the case issued in November 2008, December 2009, August 2011, July 2012, and July 2013. Therefore, any defect with respect to the timing of the VCAA notices has been cured. In regard to the Veteran's 2009 hearing, the Board notes that 38 C.F.R. § 3.103(c)(2) requires that a presiding VLJ fully explain the issues and suggest the submission of evidence that may have been overlooked. Here, questioning at the hearing focused on the elements for claim substantiation and the representative and the VLJ specifically elicited testimony from the Veteran as to the relevant clinical history and the elements necessary for service connection. Moreover, neither the Veteran nor 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. Thus, the Board finds that the hearing was legally sufficient and the duty to notify has been met. Relevant to the duty to assist, service treatment records and post-service VA and private treatment records, as well as records from VA examinations conducted in January 2005, October 2008, September 2009, October 2010, and February 2012, with a June 2013 addendum, have been obtained and considered. However, the Board notes formal findings of unavailability within the claims file as to a portion of the Veteran's active duty treatment records and his reserve records. Although these findings are within the file, the Veteran has submitted copies of what he indicated were his complete active duty treatment records and he has stated that no pertinent treatment records were generated during his reserve service. Regardless, there is documentation in the file reflecting that the AOJ has made all appropriate attempts to recover any outstanding service records. In specific regard to the Veteran's active duty treatment records, the AOJ made multiple inquiries to the service department to confirm that all available records had been mailed, generated a formal finding of unavailability, and notified the Veteran as to the status of those records in accordance with 38 C.F.R. § 3.159 (d). However, the Veteran submitted his own copies of active duty service treatment records in November 2008. The AOJ also took appropriate steps to recover records of treatment and examination generated during the Veteran's reserve service, to include contacting the service department, issuing a formal finding of unavailability, and notifying the Veteran as to the status of those records. The Veteran has stated that no pertinent reserve records exist. When, as has been contended here, service records are lost or missing through no fault of the Veteran, VA has a heightened duty to consider the applicability of the benefit of the doubt rule and to assist a claimant in developing a claim. Cromer v. Nicholson, 19 Vet. App. 215, 217-18 (2005), citing Russo v. Brown, 9 Vet. App. 46, 51 (1996). See also Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). Although the claims file now appears complete, the Board finds that VA has met this heightened duty. As multiple inquiries have been made to obtain the outstanding records and the AOJ has both been informed that no additional records are available and has appropriately informed the Veteran - and the Veteran has submitted copies of the only outstanding records that he says exist - the Board also finds that any further efforts to obtain these records would be futile. Neither the Veteran nor his representative has identified any additional, outstanding records pertinent to the claim herein decided that have not been requested or obtained. Therefore, the Board finds that VA has satisfied its duty to assist. Additionally, the Veteran was afforded multiple VA examinations of his left foot and toes. Most recently, he was examined in February 2012 with an addendum opinion issued in June 2013. The Board finds that the VA 2012 examination, read with the 2013 addendum opinion and in light of the prior opinions of record, is adequate to decide the issue despite the Veteran's contentions, made through his authorized representative in July and September 2013 briefs, that the February 2012 examination report, read with the March 2013 addendum opinion, was not adequate. Specifically, the Veteran contends that the examination and opinion do not provide sufficient rationale and do not adequately address aggravation. However, the Board notes that the examiner clearly stated that the opinion was based on review of the claims file and reflects analysis of the medical evidence therein. Further, the opinion rendered regarding the relationship between the Veteran's current diagnosis and in-service experience was plainly rendered based on the examiner's medical training, clinical experience, and interpretation of the Veteran's clinical findings as well as analysis of medical evidence in the file. The Board notes that the examiner who interviewed and examined the Veteran in 2012 also provided the 2013 opinion. Moreover, despite the Veteran's contentions to the contrary, the examiner's opinions offer clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Further, the examiner addressed aggravation by observing that no left foot or toe disability existed prior to service and, therefore, could not have been aggravated by service - despite checking a box that denotes aggravation, the text of the opinion clearly reflects that check was a mistake (the examiner stated directly under that checked box that the Veteran's foot disabilities "occurred years after service") and provides an adequate rationale. Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the issue decided herein has been met. The Board remanded this case in June 2009, September 2010, October 2011, and March 2013 in order for the AOJ to ensure that all identified and available records were associated with the claims file, to afford the Veteran examinations, to gather a clarifying medical opinion, and to further develop the claim by assisting him in gathering any additional evidence that he may identify. The record reflects that the AOJ made all appropriate efforts to obtain outstanding records, has appropriately advised the Veteran of those efforts, and has afforded him multiple examinations, with an addendum opinion issued in June 2013. The AOJ also issued December 2009, August 2011, July 2012, and June 2013 supplemental statements of the case reflecting readjudication of the claim after each remand. Therefore, the Board finds that the prior remand directives have been substantially complied with such that no further action is necessary in this regard. See D'Aries, supra. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claim. II. Analysis Under relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in, or aggravated by, active service. 38 U.S.C.A. §§ 1110, 1131. Here, the Veteran contends that he experiences current disability of his left foot, specifically the great toe, as the direct result of an in-service injury. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in- service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. In some cases, service connection may also be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307) and (ii) subsequent manifestations of the same chronic disease, or (b) if the fact of chronicity in service in not adequately supported, by evidence of continuity of symptomatology. However, the United States Court of Appeals for the Federal Circuit has held that the provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Inasmuch as the evidence reflects degenerative changes in the left great toe - i.e. arthritis, a disease recognized as chronic under 38 C.F.R. § 3.309(a) - the provisions of 38 C.F.R. § 3.303(b) pertaining to continuity of symptomatology are applicable. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). 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) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). However, here the Veteran does not contend, and the evidence does not otherwise indicate, that he experiences disability of his left foot/toes as the result of a service-connected disability. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran's service treatment records show that his feet were evaluated as normal at both the time of his enlistment examination in August 1984 and his separation examination in June 1990. Although a July 1986 treatment note reflects that the Veteran complained of left great toe pain after "twisting it going up a stair," it also states that x-ray was negative. However, the Veteran was diagnosed with a contusion with "possible tendinous involvement." The treating clinician noted that he had full range of motion of the toe, which was neurovascularly intact. The clinician advised heat and elevation, as well as painkillers and follow-up on an 'as needed' basis. A radiologic report dated later in July 1986 reiterates a normal study of the left foot. Subsequently, a May 1988 performance review notes that the Veteran participated on the "squadron flag football team" and a June 1989 note observes that the Veteran had no physical barriers to training. After service, the Veteran submitted a claim of entitlement to service-connection for hypertension in 1990, but did not mention any foot disability. In October 2004, he submitted another claim and, at that time, referenced foot and toe disability. The Veteran referred to those disabilities as "gout" and provided VA with a copy of a private podiatry record dated October 1998 which stated that the Veteran had begun wearing new boots approximately three months prior and was, at that time, experiencing diffuse foot pain and had "recurrent lesions, plantar aspect right great toe and left great toe joint." Foot x-rays showed "osteophytic lipping... dorsally at the talonavicular joint with degenerative changes at the talonavicular, as well as navicular cuneiform joints, bilaterally." The private podiatrist stated that he debrided lesions on the left and right great toes and also observed that the Veteran had not been wearing custom orthotics. Earlier private treatment records reflect that the orthotics were provided in October 1996 after the Veteran was diagnosed with right sesamoiditis and left bursitis at the second metatarsal-phalangeal joint. Treatment notes reflect that the Veteran initially reported foot pain in August 1996, but stated he did not have any specific foot trauma and simply worked on his feet in steel-toed boots for approximately seven hours each day. A March 1997 note reflects continued treatment of the bursitis of the left second metatarsal-phalangeal joint - there was painful motion of that joint as well as "punctuate lesion" under the left first metatarsal-phalangeal joint. The plantar lesions were debrided and the Veteran was advised to continue wearing his orthotics. The Veteran was seen for "pain at the top of the l[eft] foot" in March 1998. He informed the podiatrist that it began hurting at work and he denied any trauma. An October 1998 note continues to reflect that he was using orthotics and attributed some of his foot pain to sciatica. In September 2003, the Veteran was diagnosed with gouty arthritis of the right first metatarsal-phalangeal joint. A September 2004 VA treatment note indicates diagnosis of gout as well as "foot pain related to sciatica per podiatry no[t]e dated 10/98." The Veteran wrote to VA in November 2004 and contended that "I still have severe pain" since the in-service injury to his toe. VA afforded the Veteran an examination in January 2005. The report reflects that he informed the examiner that he had a foot condition ever since 1986 that has manifested with pain, weakness, stiffness, and fatigue. The examiner did not diagnose any disability of the bilateral toes because there was "no pathology to render a diagnosis." In March and April 2005, he was treated by VA for bilateral pes planus and tibial sesamoiditis. In an April 2005 statement, the Veteran reported that "since the mid to late 1990's [his] physical activity has been limited" as a result of having "busted [his] toe (on brick stairs not twisting it)." He also stated that he was filing a claim for the underlying toe disability and "was not filing a claim for gout." An April 2005 VA x-ray revealed "no evidence of acute injury or destructive process" of the bilateral feet. At a June 2005 VA appointment, he stated that his symptoms had been present ever since service. An October 2005 VA treatment note reflects diagnosis of bilateral tibial sesamoiditis and states that the Veteran reported long standing pain in the bilateral great toe joints. In January 2006, the Veteran reported for VA treatment and stated that he had experienced ongoing foot pain for the last eight to ten years. A February 2006 VA treatment note states that the Veteran experienced bilateral foot disabilities to include painful hallux motion. He was diagnosed, again, with tibial sesamoiditis and pes planus. The Veteran noted on his March 2006 substantive appeal that he had not injured his foot after service and noted that a private practitioner, Dr. Bouchard, had diagnosed him with post-traumatic arthritis. A March 2006 note from Dr. Bouchard states that x-rays of the Veteran's feet revealed post-traumatic arthritis of the right ankle as well as splay foot with bilateral bunion deformity and "some lytic changes around the 1st MPJ." In April 2006, Dr. Bouchard saw the Veteran on multiple occasions and diagnosed "bursitis-bunion left" and "tenosynovitis left 5th MPJ. In an April 2006 statement to VA, the Veteran again contended that his foot disabilities began in the 1980's and "began later causing [him] pain." A June 2006 treatment note from Dr. Bouchard states that the Veteran had "bursitis-bunion left great toe joint" and had informed him that it was due to a July 1986 in-service injury to the same toe. In September 2006, Dr. Bouchard stated that the Veteran's pain and tenderness of the first metatarsal-phalangeal joint of the left foot was responding to injection therapy - the diagnosis listed was tenosynovitis of that joint. In August 2007, VA x-ray of the feet revealed "early degenerative change... involving the first MTP joint bilaterally." A November 2007 treatment note identifies "1st MPJ" degenerative joint disease bilaterally, but left greater than right. However, a September 2007 VA treatment note states that "foot exam did not reveal any hyperkeratotic lesions from any structural or biomechanic problems" and range of motion of the first metatarsal phalangeal joint was normal. Although the Veteran was afforded another VA examination in October 2008, the examiner only assessed hypertension and disability of the right ankle. During the February 2009 hearing, the Veteran testified that, during the in-service injury to his left great toe, the toe was "jammed back." He testified that, as a result of the injury, he was "on crutches for maybe a month, month and a half or so" and "after that time [] it gradually got better," but also recurred "when the weather started getting bad... [and] standing longer periods of time, even running." In May 2009, he underwent private surgery of the left foot. One of the Veteran's private podiatrists, Dr. Bordenkercher, wrote a March 2010 letter stating that the Veteran had traumatic arthritis of the hallux interphalangeal joint and noting that he attributed it to an in-service injury in which the toe was hyperextended backwards. In an April 2010, the same doctor observed that the Veteran had pain in the interphalangeal joint of the left hallux, where the in-service injury occurred. The podiatrist stated that he had reviewed the Veteran's service treatment records that discussed the injury and, on the basis of that review, opined that the current traumatic arthritis was more likely than not related to his military service. Private treatment notes from March, April, and May 2010 note left hallux and big toe arthritis. In October 2010, VA afforded the Veteran another examination. The examiner noted that prior VA podiatry evaluations have shown progressive, symmetrical bilateral mild degenerative joint disease of the feet, to include the metatarsal-phalangeal joints. After reviewing the record and examining the Veteran, the examiner observed that he had "active, untreated gout," which "specifically targets the big toe." For that reason, as well as the bilateral nature of the changes, the examiner opined that the current left foot/toe disability was less likely than not related to the in-service injury. VA afforded the Veteran another examination in February 2012. The examiner noted that he had been diagnosed with flat foot and hallux valgus. The Veteran informed the examiner that his injury was incurred in service and required that he remain on crutches for over a month. The Veteran also informed the examiner that his left foot was chronically painful thereafter, but he had been able to "treat himself now and then as his left foot and toe were swollen." Upon examination, the examiner observed bilateral hallux valgus and fallen arches. Upon x-ray, the examiner described mild degenerative, rather than traumatic, changes to the left great toe and opined against an etiological relationship to the in-service 1986 injury. In providing an opinion, the examiner noted that the Veteran's report of crutches was inconsistent with the service treatment records and stated that "normally" an injury such as the one described by the Veteran "resolves without sequelae." The examiner also noted that the Veteran's condition should be unilateral if it was the result of the in-service injury, but observed that he had bilateral foot/toe disabilities. However, the examiner acknowledged the Veteran's reports of chronic pain and stated that hallux valgus and flat feet are congenital conditions. October 2012 VA treatment notes reflect continued treatment of gout as well as the Veteran's inquiry as to why x-ray showed degeneration of the left great toe - a VA staff physician noted that the x-ray showed "djd, and erosion, which can happen after injury." In an April 2013 letter, the Veteran again described the in-service injury to his left great toe. He also stated that he was treated in service "and recovered." He stated that he never received any further treatment from the military - whether on active duty or in the reserves - for his left foot/toe and that he began having "foot problems years later, after [he] left the military." In June 2013, the February 2012 VA examiner provider an addendum opinion. She indicated that the full claims file was reviewed, but again opined that no current left foot disability was likely the result of any incident of service. She explained that all service records, including periodic examinations, were negative for findings of hallux valgus, pes planus, or any chronic foot or toe disability. As a result, she explained that these disabilities occurred after, rather than before or during service, and "from all indications," the Veteran "sustained soft tissue contusion in 1986 which clearly resolved without sequelae." In addressing the use of the word "congenital" in the prior (February 2012) examination report, she stated that "it is reasonable to mention that certain people have genetic tendency for hallux valgus and pes planus deformities" and that "congenital or genetic factors always involve bilateral/symmetric symptoms as seen in this particular veteran." She also observed that hallux valgus can be caused by environmental factors such as wearing tight-fitting shoes. However, she opined that "given the entire review of the Veteran's medical records, it is clear that he has an acquired pes planus" as "there was no evidence of flat feet until his adulthood." She also identified multiple causes of pes planus including "prolonged stress to the foot, faulty biomechanics, obesity, or as part of the normal aging process." Initially, the Board notes that the use of the word "congenital" as used in the 2012 VA examination raises the possibility that a left foot/toe disability pre-existed service. See Robinson v. Peake, 21 Vet. App. 545, 552 (2008) (the Board must address theories of entitlement raised by the Veteran or by the evidence of record). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has distinguished between those cases in which a preexisting condition is noted upon entry into service, and those cases in which preexistence of the condition must otherwise be established. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); Horn v. Shinseki, 25 Vet.App. 231, 234 (2012); see also 38 U.S.C. § 1111 (presumption of sound condition). In a case where there is no preexisting condition noted upon entry into service, the Veteran is presumed to have entered service in sound condition, and the burden falls to the government to demonstrate by clear and unmistakable evidence that (a) the condition preexisted service and (b) the preexisting condition was not aggravated by service. Wagner, 370 F3d. at 1345; Horn, 25 Vet.App. at 234; 38 U.S.C. § 1111. Here, the Board finds that the condition of a left foot or toe disability was not noted upon entry into service. Further, the Veteran has not contended that it pre-existed service, no relevant disability was noted on the entrance examination, and no probative evidence suggests otherwise. Accordingly, the presumption of soundness applies. The Veteran contends on his own behalf and through his authorized representative that he has a left foot, to include great toe, disability that was incurred in, and has existed since, service. A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom., Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998). However, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (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 Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it pertains to the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). In the instant case, the Board finds that the Veteran, as a lay person, is competent to report experiencing pain in his left foot and toes. Further, as the Veteran received medical training in service and served as a medic, he may be considered competent to provide an opinion as to the etiology of his current left foot/toe disability. However, the Board also has a duty to assess the credibility of the evidence. Smith v. Derwinski, 1 Vet. App. 235, 237-38 (1991); Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence of an in-service event (see Buchanan v. Nicholson, 451 F.3d 1331, 1337 (2006)), but, the Board may discount the credibility of evidence in light of its own inherent characteristics and its relationship to other items of evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. See Caluza v. Brown, 7 Vet. App. 498 (1995). Here, the Board notes that the Veteran has contended both that his symptoms were chronic ever since the in-service injury and that the injury healed and did not result in symptoms until years later. The Veteran's service treatment and examination records do not support his contention that he experienced any disability of the left foot/toe after the initial injury healed. Moreover, the service records do not support his contention that he was on crutches for over a month to treat the injury. The private medical evidence of record does not reflect any left foot or toe symptoms until 1996, at which time he denied any specific trauma but complained of working on his feet in steel-toed boots for approximately seven hours each day. Although the Board considers the Veteran competent to report his symptoms (Layno v. Brown, 6 Vet. App. 465, 469 (1994)), it finds his contentions not credible due to inconsistency and implausibility. Specifically, his report of the duration of his symptoms and treatment in service is inconsistent with the medical evidence of record and the Board finds it implausible that, had he experienced intermittent pain ever since the 1986 injury, he would have been active on a squadron football team during the remainder of his military service, would not have sought any treatment until nearly a decade after the injury, would have accepted employment requiring standing for prolonged durations of time, and, when initially seeking post-service treatment, would not have reported the prior injury. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment); See Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I.2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). Moreover, contemporaneous evidence has greater probative value than subsequently reported history (Curry v. Brown, 7 Vet. App. 59, 68 (1994)) and the contemporaneous evidence here reflects normal feet upon discharge from active duty. For the above reasons, the Board finds that there is no showing of any chronic left foot/toe disability in service. Further, since in-service x-ray and post-service x-rays dated prior to August 2007 do not show any arthritis in the left foot/toe, and as the Veteran's contentions as to continuity of symptoms since service are not credible, there is no showing of continuity as to satisfy 38 C.F.R. § 3.303 (b). The Veteran cannot support his claim on the basis of his own assertions of continuity of symptomatology, alone. See Walker, 708 F.3d 1331. Moreover, although the Veteran, by virtue of his military medical training, may be considered competent to render an etiological opinion, his contentions as to etiology are similarly not credible as they are based on his incredible assertions as to the in-service treatment and post service symptomatology. Caluza, 7 Vet. App. 498. Although one private physician, Dr. Bouchard, noted that the Veteran attributed his left foot/toe disability to an in-service event, he did not actually render such an opinion and the reiteration of the Veteran's opinion by a doctor does not confer any additional competency or credibility. See LeShore v. Brown, 8 Vet. App. 406, 409 (1995). Moreover, the Board observes that, although the Veteran attested that Dr. Bouchard had diagnosed him with traumatic arthritis, review of the record reflects that diagnosis by Dr. Bouchard was rendered in regard to the right ankle - the Veteran was first privately diagnosed with traumatic arthritis of the left great toe by Dr. Bordenkercher at a later date. Dr. Bordenkercher and an October 2012 VA physician authored opinions that appear to support the Veteran's contention that his current left foot/toe disability is causally related to the in-service 1986 injury. However, in regard to the October 2012 VA physician, the Board notes that he explained that "djd, and erosion, [] can happen after injury," but did not explicitly address the in-service injury experienced by the Veteran or provide an opinion linking any current disability to any specific event. The opinion is speculative in nature and the Board notes that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. Jones v. Shinseki, 23 Vet. App. 382, 389-90 (2010); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Goss v. Brown, 9 Vet. App. 109, 114 (1996); Obert v. Brown, 5 Vet. App. 30, 33 (1993); Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521 (1996). Applicable regulations also provide that a finding of service connection may not be based on a remote possibility. See 38 C.F.R. § 3.102. Regardless, the opinion provided by Dr. Bordenkercher was not speculative in nature. Dr. Bordenkercher stated that he had reviewed the Veteran's service records that documented his injury and, on the basis of that review and the Veteran's private treatment history, opined it was more likely than not that current arthritis in the left great toe was the result of the in-service injury. However, multiple VA examiners have opined to the contrary on the basis of review of all service treatment records, private records, and VA records. Moreover, more than one of those examiners have provided additional rationale, explaining that the bilateral and symmetrical nature of the Veteran's foot and toe disabilities contraindicate a finding that an injury to the left side caused the current left toe disability. Specifically, in October 2010, an examiner observed progressive, symmetrical bilateral mild degenerative joint disease of the feet, to include the metatarsal-phalangeal joints. Based on the nature of the changes to those joints, the examiner explained that the disabilities were less likely than not related to service. The February 2012 examiner made a similar observation, commenting that, if the current disability resulted from in-service injury, it should be unilateral. The 2012 examiner specifically noted that none of the Veteran's current foot disabilities would have stemmed from the documented in-service injury to the left great toe and explained that the nature of the in-service injury was soft-tissue, rather than bone and, as such, would not cause a bone-related problem. Moreover, that same examiner clarified in 2013 that the evidence of record showed that the Veteran experienced "soft tissue contusion in 1986 which clearly resolved without sequelae." When faced with conflicting medical opinions, the Board must weigh the credibility and probative value each of the opinions, and in so doing, the Board may favor one medical opinion over the other. See Evans v. West, 12 Vet. App. 22, 30 (1998) (citing Owens v. Brown, 7 Vet. App. 429, 433 (1995)). In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez, supra. Initially, the Board will assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. Second, the Board will consider whether or not the medical expert provided a fully articulated opinion. Id. Finally, the Board considers whether the opinion is supported by a reasoned analysis. See Nieves-Rodriguez, supra; Stefl, supra. Here, only the VA examiners reviewed the entire claims file, but the Board notes that review of the claims file is not required since a medical professional can also become aware of the relevant medical history by having treated a Veteran, as had his private podiatrist. Id. at 303-04. However, here, it does not appear as though the private podiatrist was fully informed of pertinent factual premises as it does not reflect awareness of the normal separation examination or the Veteran's statements as to post-service symptom continuity. Second, the private podiatrist did not provide a fully articulated opinion as he did not discuss the Veteran's contentions as continuity or to in-service treatment and did not address the bilateral nature of the foot disabilities. In contrast, the VA examiners both discussed the Veteran's contentions and analyzed the nature of the current left foot/toe disabilities in relationship to the treatment history. Finally, different from the medical reasoning provided by the VA examiners, the private podiatrist simply attributed his opinion to a file review (which, as noted, did not appear to be complete). See Nieves-Rodriguez, supra; Stefl, supra. For these reasons, the Board finds the opinions of the VA examiners most probative. Evans, 12 Vet. App. at 30; Winsett v. West, 11 Vet. App. 420 (1998), aff'd 217 F.3d 854 (Fed. Cir. 1999). The Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a left foot/toe disorder. As such, the benefit-of-the-doubt doctrine is not applicable to this issue and the claim must be denied. 38 U.S.C.A. § 5107. ORDER Service connection for a left foot and toe disorder is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs