Citation Nr: 1339198 Decision Date: 11/27/13 Archive Date: 12/13/13 DOCKET NO. 07-21 883 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for a right foot disability, to include as secondary to a service-connected right ankle sprain disability. 2. Entitlement to service connection for a right great toe disability, to include as secondary to a service-connected right ankle sprain disability. REPRESENTATION Appellant represented by: Eric Gang, Attorney ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from July 1982 to July 1985. These matters come before the Board of Veterans' Appeals (Board) from a February 2006 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Waco, Texas. These matters were previously before the Board in November 2010, April 2012, and January 2013 and were remanded for further development. They have now returned to the Board for further appellate consideration. The Board finds that there has been substantial compliance with the mandates of its remands and will proceed to adjudicate the appeal. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is 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). FINDINGS OF FACT 1. The Veteran is service-connected for a right ankle sprain disability. 2. The earliest clinical evidence of a right foot disability is in 2005, 20 years after separation from service. 3. The Veteran is less than credible with regard to the onset of his current right foot disability. 4. The competent credible evidence of record is against a finding that the Veteran has a right foot disability causally related to, or aggravated by, active service or a service-connected disability. 5. The earliest clinical evidence of a right great toe disability is in 2005, 20 years after separation from service. 6. The Veteran is less than credible with regard to the onset of his current right great toe disability. 7. The competent credible evidence of record is against a finding that the Veteran has a right great toe disability causally related to, or aggravated by, active service or a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a right foot disability (to include pes planus and plantar fasciitis) have not been met. 38 U.S.C.A. §§ 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2013). 2. The criteria for service connection for a right great toe disability (to include hallux valgus and degenerative joint disease) have not been met. 38 U.S.C.A. §§ 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided in October 2005. The notice was deficient in that it did not inform the Veteran of the evidence necessary to substantiate the claims on a secondary basis or provide notice in accordance with Dingess with regard to an effective date and assignment of a rating in the event that service-connection is awarded. The Board finds that the Veteran has not been prejudiced by this lack of prior notice with regard to the assignment of an effective date and rating because the Board, in the decision below, denies the Veteran's claims for entitlement to service connection; thus, there can be no award of an effective date or rating. The Veteran was informed in November 2010 correspondence that VA would also consider whether his disabilities warranted service connection on a secondary basis. The Board finds that the appellant has not been prejudiced by any notice defect as to the criteria for service connection on a secondary basis. The law with regard to secondary service connection was contained in the Board's November 2010 and April 2012 remands. The Board notes that the appellant has been represented by an accredited representative, and/or an attorney during his appeal. See Overton v. Nicholson, 20 Vet. App. 427, 438 (2006). The accredited representative, in a June 2013 written post-remand brief, cited to the applicable law with regard to service connection on a secondary basis. Based on the foregoing, the Board finds that the appellant has had a meaningful opportunity to participate in the adjudication of his claims such that the essential fairness of the adjudication is not affected. The Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of VA's notice or other development. See Shinseki v. Sanders, 129 U.S. 1696 (2009). VA has a duty to assist the appellant in the development of the claims. The claims file includes service treatment records (STRs), VA and private medical records, lay statements, and the statements of the Veteran in support of the claims. A December 2005 formal finding of unavailability of treatment records from July 7, 1985 is also of record. (The Board notes that this would have been the Veteran's last day of active service.) The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The claims file includes VA examinations and/or opinions from 2007, 2010, 2012, and 2013. Although some of the opinions were inadequate in certain aspects, the Board finds that when they are taken together, there has been an adequate examination and opinion upon which the Board may base its findings. Adequate rationale based on the Veteran's history, clinical records, and clinical findings has been provided. The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Service Connection in general Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" 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. 38 C.F.R. § 3.303(b). For the showing of a '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. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease," whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Service Connection on a secondary basis Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). During the course of this appeal, VA amended 38 C.F.R. § 3.310 effective October 10, 2006), to implement the decision in Allen. See 71 Fed. Reg. 52,744 -47 (Sept. 7, 2006). The amended 38 C.F.R. § 3.310 (b) institutes additional evidentiary requirements and hurdles that must be satisfied before aggravation may be conceded and service connection granted. o whatever extent the revised regulation may be more restrictive than the previous one, the Board will afford the Veteran review under both the old and new versions. See VAOPGCPREC 7-2003 (Nov. 19, 2003). Analysis The Board has reviewed all of the evidence in the Veteran's claim file, with an emphasis on the evidence relevant to this appeal. 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 of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Right Foot Disability The Veteran avers that he has a right foot disability causally related to active service, to include as secondary to a service-connected right ankle sprain disability. An essential element of a claim for service connection is evidence of a current disability. The Veteran has been diagnosed with pes planus and plantar fasciitis of the right foot. Thus, this element has been met. A second requirement for service connection is medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease. The Veteran's STRs are negative for any complaints of, or treatment for, pes planus and/or plantar fasciitis. The Veteran's May 1982 report of medical history for enlistment purposes reflects that the Veteran denied any foot trouble. The May 1982 report of medical examination reflects that his feet were normal upon clinical examination. Approximately two years after entrance into service, an April 16, 1984 record reflects that the Veteran was involved in a motor vehicle accident and had tenderness to the right lateral malleolus with no swelling. An April 17, 1984 follow-up record reflects that the Veteran had swelling in the right ankle and knee, pain to palpation, and decreased range of motion. The assessment was soft tissue injuries. He was to ambulate with crutches, elevate the leg, and take Tylenol. A July 1984 DA Form 2631 reflects that the Veteran was in a motor vehicle accident on April 16, 1984. It was noted that he was treated on April 16, April 17, and July 1, 1984, for a total of three visits for a right ankle contusion. A July 1984 STR reflects that the Veteran had pain in the right hand and right ankle. It was noted that he was playing ball and injured his finger. A July 16, 1984 STR reflects that the Veteran had been involved in a motor vehicle accident in April 1984 and had been on crutches for three days. He had been unable to wear a shoe for five days after the injury. He complained of current pain with pressure on the ankle such as when going up and down stairs. X-rays were normal. He had mild swelling and tenderness of the lateral ankle. The assessment was status post right ankle sprain. The claims file does not include reports of medical history or medical examination upon separation. Nonetheless, the clinical records of evidence, which deal with the right lower extremity, are negative for any findings of pes planus and/or plantar fasciitis. The Board finds that if the Veteran had been having complaints of, or treatment for, pes planus or plantar fasciitis, it would have been reasonable for them to have been noted when he had complaints with regard to the ankle and was having his lower extremity examined. A third requirement for service connection is competent credible evidence of a nexus between the current disability and the in-service disease or injury. The Board finds, for the reasons noted below, that this third requirement for service connection has not been met. August 2005 VA clinical records reflect that the Veteran reported complaints of foot pain. An August 19, 2005 report reflects that the Veteran had reported swelling since he stopped taking HTCZ (Hydrochlorothiazide). The August 22, 2005 record reflects that he had complaints of pain in the feet for the last "several months." The records do not reflect that the Veteran had pain since service or that it was due to, or aggravated by, service or a service-connected disability. The claims file includes an August 2007 VA examination report with regard to the right ankle. It reflects that the Veteran reported a soft tissue injury of the right ankle in service. It was noted that he "does not remember any other injuries." It was further noted that he works at a post office and walks and stands for eight hours a day. A December 2010 VA examination report reflects that the Veteran reported that he has had pain in his right foot since the injury in service. He reported that he works at the bulk mail center for the post office and stands most of the day. The examiner found no radiographic evidence of pes planus; however, upon physical examination, the Veteran had moderate pes planus bilaterally. He had a normal gait with no evidence of painful motion, edema, instability, or weakness. There were no calluses, skin breakdown, or unusual shoe wear patterns. He was diagnosed with bilateral pes planus with secondary bilateral hallux valgus with plantar fasciitis on the right foot, which was not caused by or the result of active military service. The examiner stated that there was no evidence in the STRs of any problems associated with pes planus on active duty. The examiner found no evidence of aggravation of problems associated with the pes planus while in active military service. The examiner stated "I know of no medical authority or medical literature which associates chronic ankle pain with the development of plantar fasciitis or hallux valgus. The plantar fasciitis and hallux valgus in the right foot are expected outcomes and problems associated with congenital pes plans. I find no evidence that the plantar fasciitis or hallux valgus are related to the right ankle strain which is currently service-connected." A May 2012 VA examination report reflects that the Veteran has bilateral pes planus. It reflects that the Veteran reported that he has had pain in his right foot since the accident in 1984. He reported that the pain was over the plantar surface and dorsal arch bilaterally. It was noted that the Veteran has worked for the postal service since 1986 and currently moves mail in a stand-up vehicle all day. The examiner opined that it is less likely as not that the Veteran's current bilateral pes planus was caused by or the result of his military service. The examiner stated, in pertinent part, as follows: The service medical records are, again reviewed, and I find no medical visits with regard to foot conditions on either foot while the veteran was in active service. The accident in 1984 clearly injured the veteran's right lateral ankle, however no left or right foot injury is noted on any notes with regard to that injury. The veteran made no complaints while on active duty over 25 years ago, with regard to either foot. Pes planus is generally an anomaly which is not noted until an individual is weight bearing, and is only noted then, when symptoms occur. No foot injuries are noted in the service medical records which would account for an acquired pes planus. He has no history since discharge of such an injury. It is more likely as not that the pes planus is congenital in its etiology. The examiner also opined that it is less likely as not that the Veteran's pes planus was aggravated by service. The examiner stated that there were no secondary conditions noted in active service, and no complaints of foot pain, hallux valgus, or pes planus, in service. The examiner stated that it is less likely as not that the Veteran's current bilateral plantar fasciitis was caused by, the result of, or aggravated by, active military service. The examiner noted that there was no evidence of foot disabilities in service, and the Veteran has been engaged in employment requiring prolonged standing and walking the 25 years since discharge, and this is at least as likely as not the cause of the Veteran's current plantar fasciitis. The Board acknowledges that the examiner stated that the Veteran's pes planus was more likely congenital in its etiology. A congenital defect is not a disability for which service connection can be granted. 38 C.F.R. §§ 3.303(c); 4.9. If the defect is aggravated by service such that a superimposed disease or injury occurred during service, service connection may be established for the resultant disability. VAOPGCPREC 82-90. The presumption of soundness does not apply to congenital defects. Quirin v. Shinseki, 22 Vet. App 390 (2009). A February 2013 VA clinical addendum is also of record. The clinician stated the following: I found no evidence of [current pes planus] in the service medical records. Pes planus can be congenital, usually manifested in adolescence, or acquired. There was no evidence of congenital pes planus in the service medical records. No medical notes regarding the feet were found. The veteran had a right ankle injury in an MVA in 1984, no foot complaints were noted, however, an xray accomplished for completeness with [sic] negative for any foot conditions. The current pes planus is not congenital. Thus, the competent credible evidence reflects that the Veteran has pes planus which was acquired after service, is not caused by, or aggravated by service, or a service-connected disability. The Board notes that even if the Veteran's pes planus were congenital in etiology, the competent credible evidence is against a finding that he has a superimposed disease or injury which occurred during service, or a result of service. The evidence is also against a finding that, if it were a congenital disease (as opposed to a congenital defect) it was aggravated beyond normal progression during his service. The 2013 clinician also stated that it is less likely as not that the Veteran's current right foot plantar fasciitis had its onset in active military service, or that his current right foot conditions were caused by, or aggravated by, or the result of the Veteran's in-service right foot sprain. The clinician stated , in pertinent part, as follows: I know of no medical authority or peer reviewed medical literature which supports the above contention [that the disabilities are secondary to a right ankle sprain disability]. The veteran's right hallux valgus and chronic plantar fasciitis are more likely as not caused by, aggravated by, and the result of his pes planus. . . .Hallux valgus, DJD of the MP joints, hammertoes, and chronic plantar fasciitis are accepted secondary conditions which often develop ini [sic] individuals with chronic pes planus." In sum, there is no competent credible clinical opinion of record that the Veteran has a right foot disability causally related to, or aggravated by, service or a service-connected disability. To the contrary, the clinical opinions are against such a finding. The clinical opinions, when taken together, reflect that the Veteran has pes planus related to years of post-service employment which required extensive standing and walking. His other right foot disabilities are due to his non-service connected pes planus, and are not aggravated by a service-connected disability. The Board has considered the numerous lay statements of record, but finds that they do not support a finding of service connection for a foot disability. A June 2012 statement from [?] G. reflects that the Veteran has a job which requires constant standing. G. stated that "over the course of fifteen plus years working with [the Veteran], I notice his form in his walk has change from a brisk step into a slow walk with a limp." Thus, according to G., the Veteran was walking fine when he initially started his post-service employment. A June 2012 statement from J. P. reflects that "over the years" he has noticed the difficulty that the Veteran has with his job duties. He stated that the duties include "riding a jitney/tow motor which requires constant pressure on the pedals that also contributes to foot and knee problems over the years I know him." This statement does not support a finding that the Veteran had a foot disability due to service, but does support the examiner's findings that the Veteran's post-service employment was the cause of his current foot disabilities. A June 2012 statement from T. H. reflects that he has known the Veteran for the past 27 years. He stated that "for the past years, I have noticed that he has been limping around a lot like he's hurting. I asked him about it and he said his feet and knees have been bothering him for quite some time. Here lately it seems to be getting worse because his job assignment requires him to stand all day long on a jitney and press two (2) pedals by feet in order to operate the equipment." T.H. also noted that he has seen the Veteran change many different types of shoes to try and relieve some of his feet pain. A June 2012 statement from S. [?] reflects that he has known the Veteran for several years. He stated that he has noticed that the Veteran's foot injury has gotten worse over the years. A June 2012 statement from K.B. reflects that the Veteran's job is to transport mail from one end of the building to the other on a jitney. K.B. stated that the Veteran has limped and had pain. A June 2012 statement from M.D. reflects that he has known the Veteran for seven years and that the Veteran has limping for "at least that long." A June 2012 statement from [V.J.?] reflects the statement that he has known the Veteran for other 26 years, and that "over the past 7 years or so, he has declined in his mobility and complains of his right foot hurting. The equipment we drive 8 hours a day you have to stand up and use your feet to operate." A June 2012 statement by V.C. reflects the statement that the Veteran has a strenuous job which requires long periods of standing, to include heavy pushing and pulling. V.C. stated that she has known the Veteran for approximately 8 years and he has complained about foot pain. A June 2012 statement by R.J. reflects that he has seen the Veteran move heavy equipment for over 26 years. In sum, the statements reflect that the Veteran has a job which requires use of his feet and is strenuous on his feet and lower extremities, and that he has had a decreased mobility or increase in pain over the years, or since at least 2004. The Veteran separated from service in 1985. Thus, after separating from service, and working in a strenuous occupation on his feet for more than a decade, he has had pain in his feet. The lay statements which reflect onset of pain seven or eight years earlier correspond roughly to the Veteran's complaints of pain in August 2005. As noted above, an August 22, 2005 record reflects that he had complaints of pain in the feet for the last "several months." None of the Veteran's coworkers or friends has been shown to have the experience necessary to differentiate between pain caused by the Veteran's right ankle disability from pain caused by other foot and/or toe disabilities, or provide a competent opinion that his disability is related to service. The Board acknowledges that the Veteran is competent to report pain. However, the Board finds that any contention by the Veteran that he has had foot pain, plantar fasciitis, and/or pes planus since service is less than credible when considered with the record as a whole. The earliest clinical evidence of pes planus or plantar fasciitis, or any foot disability, is in 2005, twenty years after separation from service. The Board acknowledges that the absence of any corroborating medical evidence supporting assertions, in and of itself, does not render lay statements incredible, such absence is for consideration in determining credibility. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (noting that the absence of contemporaneous medical documentation may go to the credibility and weight of appellant's lay testimony, but the lack of such evidence does not, in and of itself, render the lay testimony incredible). See also Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007) (noting that lay evidence can be competent to establish a diagnosis when . . . a layperson is competent to identify the medical condition.) In addition, the lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Moreover, the lay statements of record support a finding of pain and limping after post service employment, the August 2005 VA clinical record reflects onset of pain in the last "several months", and the STRs are negative for pes planus or foot complaints, other than of the ankle. The Board notes that the Veteran has not been shown to have the experience, training, or education necessary to make a competent etiology opinion as to his claimed disabilities. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issues in this case because of the possibility of multiple etiologies for the Veteran's foot complaints. The Veteran is not shown to have the education and training necessary to make a etiology findings between pes planus and plantar fasciitis clinically diagnosed more than two decades after service, and service or a service-connected disability. The Board finds that such etiology findings fall outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Moreover, the Board finds that the opinions of the medical professionals who have supplied VA opinions are more probative than those of lay persons. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Right great toe disability The Veteran has been diagnosed with hallux valgus and degenerative joint disease of the great toe. The earliest clinical evidence of a right great toe disability is 2005, approximately 20 years after separation from service. The lapse of time between service separation and the earliest documentation of current disability is a factor for consideration in deciding a service connection claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Veteran's STRs, as noted above, are negative for any complaints of, or treatment for, his right great toe. As the Veteran was treated for a right ankle injury in service, it seems reasonable that if he had another disability of the lower right extremity in close proximity to the ankle (e.g. the toe), such a disability would also have been noted. The Board finds that any statement by the Veteran that he had hallux valgus or degenerative joint disease of the great toe in service is less than credible when considered with the record as a whole. The December 2010 VA examination report note above reflects that the Veteran was diagnosed with mild bilateral hallux valgus, and mild bilateral degenerative change in the first metatarsal phalangeal joint and in the interphalangeal joint of the right great toe. The examiner stated that he knew of no medical authority or medical literature which associates chronic ankle pain with the development of hallux valgus. He also stated that hallux valgus is an expected outcome of pes planus. The Veteran is not service-connected for pes planus. The May 2012 VA examiner, noted above, opined that the hallux valgus is less likely as not due to service. The examiner noted that there was no evidence of any complaints in service. The examiner noted that "hallux valgus develops as the result of chronic pes planus, and its companion degenerative joint disease develops as the result of the hallux valgus condition. Since the condition was not present while the veteran was in active military service it is more likely than not that this condition had its onset after discharge from military service." The May 2012 VA examiner also stated that he found no evidence that the veteran's currently diagnosed right foot hallux valgus or his resultant degenerative joint disease were aggravated by the veteran's right ankle sprain, and that it was more likely as not that the right foot and right toe conditions were caused and aggravated by the veteran's pes planus combined with many years of standing and walking. The Board acknowledges that the examiner checked a DBQ (Disability Benefits Questionnaire) form box that the Veteran' s claimed condition clearly and unmistakably existed prior to service and was clearly and unmistakably not aggravated beyond is natural progression by an in-service injury or event; however, the actual rationale of the opinion is against a finding of a preexisting disability. The Board finds that the actual rationale and opinion provided by the examiner are more probative than the box the examiner checked. The February 2013 VA clinical addendum reflects the opinion of the clinician that it is less likely as not that the Veteran's current right toe hallux valgus had its onset in active military service. The clinician also stated the veteran's right hallux valgus is more likely as not caused by, aggravated by, and the result of his pes planus. In sum, there is no competent credible opinion of record that the Veteran has a right great toe disability causally related to, or aggravated by, service or a service-connected disability. To the contrary, the clinical opinions are against such a finding. The clinical opinions, when taken together, reflect that the Veteran has pes planus acquired after service related to years of post-service employment which required extensive standing and walking. His toe disabilities are due to his non-service connected pes planus, and are not aggravated by a service-connected disability. The Board has considered the numerous lay statements of record, as noted above, but finds that they do not support a finding of service connection for a great toe disability. The statements reflect that the Veteran has a job which requires use of his feet and is strenuous on his feet and lower extremities, and that he has had a decreased mobility or increase in pain since working there; however, the statements are not specific to the great toe and do not support a finding that his great toe disabilities are caused by, or aggravated by, service or a service-connected disability. In a November 2010 statement (VA Form 21-4138), the Veteran stated that he has aged and with "his line of work," his toe has been aggravated by the stress of pushing and pulling on equipment for nearly 25 years. While the Veteran is competent to report pain, and the witnesses are competent to report their observations of the Veteran, none of them has been shown to have the experience, training, or education necessary to make an etiology opinion to the claimed disabilities. The Board finds that a lay person is not competent to provide a probative opinion as to the specific issues in this case in light of the education and training necessary to make a finding with regard to the pes planus and any possible relationship between it and extensive years of working on one's feet, a right ankle sprain, hallux valgus, plantar fasciitis, pes planus, and/or degenerative joint disease. The disability at issue could have multiple possible causes and thus falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Based on the record as a whole, the Board finds that the competent credible evidence of record is against a finding that the Veteran has a right great toe disability, to include hallux valgus and/or degenerative joint disease, due to, or aggravated by, service or a service-connected disability. Thus, service connection is not warranted. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107, and 38 C.F.R. § 3.102, but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert, 1 Vet. App. at 54-56. ORDER Entitlement to service connection for a right foot disability, to include as secondary to a service-connected right ankle sprain disability is denied. Entitlement to service connection for a right great toe disability, to include as secondary to a service-connected right ankle sprain disability is denied. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs