Citation Nr: 1340872 Decision Date: 12/11/13 Archive Date: 12/20/13 DOCKET NO. 08-21 293 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder, to include as secondary to service-connected left foot disability. 2. Entitlement to service connection for right knee and right ankle disorders, to include as secondary to or aggravated by service-connected disabilities, to include left foot disability. REPRESENTATION Appellant represented by: Puerto Rico Public Advocate for Veterans Affairs ATTORNEY FOR THE BOARD Tresa M. Schlecht, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c)(2012). 38 U.S.C.A. § 7107(a)(2)(West 2002). The appellant had military service in the United States Army Reserves from August 1953 to August 1961. He had a period of service in April 1958 that is considered active service because he sustained a left foot injury for which service-connected has been granted during that reserve service. The matters on appeal initially came before the Board of Veterans' Appeals (Board) from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. In a September 2007 rating decision, the RO reopened the previously denied claim of entitlement to service connection for an acquired psychiatric disorder, and denied service connection for a psychiatric disorder as secondary to service-connected left foot disability. In an April 2009 rating decision, the RO denied claims of entitlement to service connection for right knee and right ankle disorders as secondary to service-connected left foot disability. The Board issued a September 2012 decision which, in pertinent part, Remanded the claims listed on the title page of this decision. The Board's September 2012 decision also remanded claims for sensory motor peripheral neuropathy of the right leg and of the left leg as secondary to service-connected lumbar disability. In an August 2013 rating decision, the RO granted service connection for left lower radiculopathy and for right lower radiculopathy, each as secondary to service-connected degenerative joint disease, L3-L4 and L4-L5, bulging disc and posterior disc protrusion, L5-S1 (IVDS). The Veteran has not disagreed with any aspect of the August 2013 grants of service connection. The claims for service connection for neuropathy of each lower extremity have been granted, and are not before the Board for appellate review at this time. After the RO issued the August 2013 rating decision granting service connection for lower extremity radiculopathy, a VA Form 9, "Appeal to Board of Veterans' Appeals," was received by VA in September 2013. The Veteran stated, "Please withdraw this appeal," and referenced the "SOC 08/20/2013." The only document that the Board can locate in the files which is dated "08/20/2013" is the rating decision prepared on August 20, 2013. The Board does not interpret the Veteran's September 2013 communication as withdrawing any claim addressed in this decision, since the claims addressed in this decision were not addressed in the August 2103 rating decision. In July 2013, the Board requested a medical opinion from the Veterans Health Administration (VHA). The appellant was provided a copy of the VHA opinion following receipt of that opinion, and the Veteran's representative has submitted additional argument in support of the appeal. FINDINGS OF FACT 1. Although various diagnoses have been assigned for the Veteran's psychiatric complaints since 1973, the Veteran does not meet diagnostic criteria for assignment of a diagnosis of a current psychiatric disorder; and, any psychiatric condition that may exist has been found to be unrelated to any period of active service or any service connected disability. 2. A right knee or right ankle injury was not incurred during a period of active duty for training, at the time of VA examination in 1958, or at the time of later examinations or treatment from 1973 to 2005; and the degenerative changes in the Veteran right lower extremity identified in 2012, following prior radiologic examinations which failed to show such changes, are more likely due to the Veteran's age and less than likely due to service-connected left foot disability or to aggravation of any other diagnosed disorder. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder, to include as secondary to a service-connected left foot disability, are not met. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2013). 2. The criteria for service connection for a right knee disorder or right knee pain, or a right ankle disorder or right ankle pain, to include as secondary to or aggravated by a service-connected left foot disability or other service-connected disability, are not met. 38 U.S.C.A. §§ 1101, 1110, 5103, 5103A, 5107(b) (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.159, 3.303, 3.310 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to notify and a duty to assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. §§ 3.159, 3.326(a). Proper notice from VA must inform the claimant and his representative, if any, prior to the initial unfavorable decision on a claim by the agency of original jurisdiction (AOJ) of any information and any medical or lay 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); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). These notice requirements apply to all five elements of a service-connection claim (Veteran status, existence of a disability, a connection between the Veteran's service and the disability, degree of disability, and effective date of the disability). Dingess v. Nicholson, 19 Vet. App. 473 (2006). Information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded must be included. Id. Neither the Veteran nor his representative has alleged prejudice with respect to notice, as is required. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009). None is found by the Board. Indeed, VA's duty to notify has been more than satisfied. The Veteran was notified via letters dated in May 2007 and March 2009 of the criteria for establishing service connection, the evidence required in this regard, and his and VA's respective duties for obtaining evidence. He also was notified of how VA determines disability ratings and effective dates if service connection is awarded. This letter accordingly addressed all notice elements and respectively predated the initial adjudications by the AOJ/RO in September 2007 and April 2009. Nothing more was required. VA also has a duty to assist the Veteran by making all reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159(c). This duty includes assisting the Veteran in obtaining records and providing medical examinations or obtaining medical opinions when such are necessary to make a decision on the claim. 38 U.S.C.A. § 5103A(b), (c), (d) (setting forth Secretary's various duties to claimant). The Veteran has been afforded several VA examinations, including in June 2007, March 2009, December 2009, January 2010, October 2012, and December 2012, and an addendum opinion was sought in April 2013. An expert VHA opinion was obtained in August 2013. Taken together, the opinions are more than adequate. They included a review of the claims file, consideration of the Veteran's lay history, and physical/psychiatric examination and provided rationale for the opinion that were provided. VA and non-VA clinical records are associated with the claims file, and electronic records are associated with the claims files. Records were requested from the Social Security Administration (SSA) in 2001, and those records remain associated with the claims files. Service treatment records are associated with the claims file as well. Further, in conformance with the Board's 2012 Remand, the Veteran was requested in September 2012 to authorize VA to obtain records from Dr. M, identified as having treated the Veteran's right lower extremity disorder. The Veteran did not respond to that letter, did not authorize VA to obtain any records, and did not submit additional records. VA has no further duty to develop the evidence. Hence, no further notice or assistance to the Veteran is required to fulfill VA's duty to assist in the development of the claim. 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); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Board will therefore proceed with the adjudication of this appeal. Relevant Laws and Regulations, Claim for Service Connection Generally, under the 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 (West 2002). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred in the line of duty. 38 U.S.C.A. § 101(21) and (24); 38 C.F.R. § 3.6(a). ACDUTRA is, inter alia, full-time duty in the Armed Forces performed by Reserves or the National Guard for training purposes. 38 C.F.R. § 3.6(c)(1). Active military, naval, or air service also includes any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C.A. § 101(24); 38 C.F.R. § 3.6(a). INACDUTRA means, inter alia, duty other than full-time duty prescribed for Reserves or the National Guard. 38 U.S.C.A. § 101(23); 38 C.F.R. § 3.6(d). In summary, when a claim for service connection is based only on a period of ACDUTRA or INACDUTRA, there must be evidence that the appellant became disabled as a result of a disease or injury incurred or aggravated in the line of duty during the period of ACDUTRA or INACDUTRA. See 38 U.S.C. §§ 101(2), (22), (24); 38 C.F.R. § 3.6(a); Donnellan v. Shinseki, 24 Vet. App. 167, 172 (2010) Service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Service connection may be demonstrated either by showing direct service incurrence or aggravation or by using applicable presumptions, if available. Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). As to the presumption of service connection for various diseases listed under 38 C.F.R. § 3.309, which would include arthritis and psychoses such as schizophrenia, this presumption applies to anyone who served on active duty for 90 days of active, continuous service. 38 C.F.R. § 3.307(a)(1); Biggins v. Derwinski, 1 Vet. App. 474, 478 (1991). That is, various diseases subject to presumptive service connection are listed under 38 C.F.R. § 3.309 and will be service connected although not otherwise established as incurred if manifested to a compensable degree within the applicable time periods under 38 C.F.R. § 3.307. However, a claimant whose claim is based on a period of ACDUTRA or INACDUTRA cannot be entitled to the presumption of service connection for various diseases. Smith v. Shinseki, 24 Vet. App. 40, 47 (2010). See also 38 U.S.C.A. §§ 101(24)(B), 1112, 1137; 38 C.F.R. §§ 3.6(a), 3.307(a). Indeed, by definition, the presumption of service connection only applies where there is no evidence that a condition began in or was aggravated during the relevant period of service. By contrast, for a claimant whose claim is based on a period of ACDUTRA or INACDUTRA to establish entitlement to benefits, there must be some evidence that his or her condition was incurred or aggravated during the relevant period of service. Id. This contrast cannot be legally bridged. Consideration of 38 C.F.R. §§ 3.307 and 3.309 (presumption of service incurrence for certain disease) for periods of ACDUTRA or INACDUTRA is not appropriate. 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 if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Psychoses and arthritis are qualifying chronic disease. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, as discussed above, the consideration of 38 C.F.R. §§ 3.307 and 3.309 is not applicable in the present claim. It follows that application of 38 C.F.R. § 3.303(b) is likewise unwarranted for the same reasoning followed in Smith. In any event, as will be discussed, continuity of symptomatology has not been argued by the Veteran. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Additionally, when aggravation of a Veteran's nonservice-connected condition is proximately due to or the result of a service-connected condition, the Veteran shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. Allen v. Brown, 7 Vet. App. 439 (1995). The Board notes that regulations governing applications of 38 C.F.R. § 3.310 were revised in 2006, after the Veteran submitted his claims. However, given the determination below, specific discussion of the regulatory change is not required. Facts and analysis Historically, service records show that the Veteran had military service in the United States Army Reserves from August 1953 to August 1961, and that he was injured in April 1958 during a period of INACDUTRA when the bridge plate of a 98 mm gun fell on his left foot. See April 21, 1958 Extract. The Veteran suffered fractures of the left great toe and left third toe. Surgical treatment of the fractures was required. Service connection for the residuals of the left foot injury was granted effective from May 1958. 1. Claim for service connection for an acquired psychiatric disorder Service treatment records are negative for any complaints, treatment, or diagnosis of a psychiatric disorder during any period of ACDUTRA or INACDUTRA. The Veteran does not necessarily argue the contrary. An August 1973 record reflects that the Veteran sought private psychiatric evaluation. A diagnosis of schizophrenia was assigned by GBM, MD. (For reference, the Board notes that the translation of Dr. M's statement from Spanish to English is in Vol. II of the claims files.) The Veteran submitted a medical statement from DC, MD, dated in 1976. Dr. C assigned a diagnosis of anxiety neurosis. (For reference, the Board notes that the translation of this document from Spanish to English is in Vol. II.) In October 1976, the Veteran submitted a statement from EP, MD, who opined that the Veteran's current anxiety reaction with depressive features was secondary to the left foot injury the Veteran incurred in service. In 1982, the Veteran underwent psychiatric evaluation for purposes of SSA examination. The examiner, HRP, MD, assigned a diagnosis of schizophrenia. The Veteran testified at a personal hearing in March 1992. In September 1992, VA psychiatric examination disclosed that the Veteran had not worked since 1974, and was receiving disability benefits from SSA. The Veteran submitted an August 1992 opinion from ARL, MD, who stated she had treated the Veteran since July 1992. The medical statement reflects that Dr. ARL assigned a diagnosis of chronic schizophrenia. The Veteran "walked slow" and "looked sad." His memory was poor. He was monotonous in communication. He appeared very dependent on his wife. The examiner concluded that the Veteran had major depression, but no psychosis. In October 1996, the Veteran underwent psychometric testing. The Veteran, who completed high school and a few college credits, tested in the deficient range of intelligence. The provider who conducted the psychometric testing concluded that the results of an MMPI (Minnesota Multiphasic Personality Inventory) were invalid because of the Veteran's exaggeration of symptoms. The Veteran brought with him to the examination a medical statement from AR, MD, who had assigned a diagnosis of schizophrenia, the examiners (a panel of two) noted. The Veteran reported being irritable and "ill humored." The Veteran had many somatic complaints. The examiners summarized the Veteran's psychiatric history, noting the wide range of assigned diagnoses over the years. The examiners noted the Veteran's contention that his service-connected foot disability or his service-connected ulcer disorder (which had been granted as secondary to medications taken for the foot disorder) caused his psychiatric disorder. The examiners concluded that the Veteran has very strong histrionic features to his personality and that his emotional condition was exacerbating his physical disorders, not the other way around. The final diagnoses on Axis I were anxiety disorder with depression, and psychological factors affecting physical conditions. A diagnosis of strong histrionic personality features was assigned on Axis II. The Veteran submitted an October 1997 medical statement from ARL, MD (who, as noted above, had provided an earlier medical statement that the Veteran had schizophrenia). In 1997, Dr. ARL assigned a diagnosis of anxiety and opined that the Veteran's high anxiety levels could precipitate an episode of increased PUD (peptic ulcer disease). By a Board decision issued in 2003, the claim for service connection for a psychiatric disorder as secondary to service-connected ulcer disease was denied. During VA hospitalization in December 1996, the Veteran was treated for gastrointestinal and respiratory complaints, but not for a psychiatric disorder. VA outpatient treatment document the Veteran's treatment from 1996 to 2005. None of these records reflect VA treatment for a psychiatric disorder. The examiner who conducted a June 2007 psychiatric examination assigned a diagnosis of schizophrenia. It was noted that the Veteran's symptoms could be expressed as major depressive disorder or generalized anxiety disorder. Specific to the claim of entitlement to service connection for an acquired psychiatric disorder as secondary to a service-connected left foot disability, the Veteran underwent VA examination in October 2012. The examiner opined that the Veteran had a current acquired psychiatric disorder, diagnosed as dementia. The Veteran was unable to remember details of his history, but did recall that he worked as an optician following his service separation in 1961. He reported that he now receives Social Security Administration benefits for disability. He reported having received mental health treatment at the "Lulia Clinic." The Veteran was unable to remember when he received the treatment, other than that it was a "long time ago, and he was unable to remember what diagnosis was assigned at the time of the treatment. The examiner stated that review of the clinical records showed that the Veteran received psychiatric treatment in 1975, some 14 years after his service discharge. The examiner opined that, given the time lapse between the Veteran's service and the foot injury incurred in service, it was less than likely that the disorder treated at that time (1975) was due to the service-connected disability. The examiner concluded that the only diagnosis supported by the Veteran's examination and history was dementia, not otherwise specified, based on the Veteran's memory loss and impairment of short- and long-term memory. The examiner concluded that the current dementia was not due to or a result of the Veteran's service or any service-connected disability, to include ulcer disease or a left foot disability. In an August 2013 opinion, the VHA reviewer summarized the clinical evidence he found relevant. The reviewer discussed the 1973 evidence that a private psychiatrist, GB, MD, indicated that the Veteran had anxiety due to bronchial asthma, but also indicated that the Veteran might have schizophrenia. The VHA reviewer noted that the private provider acknowledged that the Veteran might be "faking" some of his symptoms. The VHA reviewer also noted that it was a "broadly-accepted fact that first-onset schizophrenia would be a very unusual diagnosis for a 39 year-old man who had normal psychological functioning" prior to age 39. The reviewer compared the 1975 diagnosis of anxiety due to left foot pain to the 1973 evidence and the 1982 medical statement that Veteran possibly had schizophrenia. In 1982, the Veteran reported auditory and visual hallucinations and the ability to see extraterrestrial beings. As set forth above, no examiner other than the provider who conducted the 1982 examination noted a report of auditory or visual hallucinations or the ability to see extraterrestrial beings. With regard to the possible diagnoses of claustrophobia, schizoaffective disorder, or an anxiety disorder due to a duodenal ulcer that were raised in April 1996, the VHA examiner noted that the presumed core diagnosis was not identified. The reviewer discussed the reports of the December 2007 and October 2012 VA examinations. The VHA reviewer noted that neither VA examiner provided a description of symptoms which would allow for an expert conclusion of "any DSM IV condition." The reviewer additionally noted that several examiners had raised serious concerns about the Veteran's veracity, his tendency to exaggerate, or his tendency to withhold symptom information. The reviewer concluded that there was no conclusive evidence from any mental health professional that the Veteran had an enduring secondary mood disorder or anxiety disorder secondary to any service-connected disability. Based on the "serious questions" about the Veteran's veracity, and the "notable lack of consensus: by evaluating providers, the VHA examiner concluded that it was less than likely that the Veteran had a current psychiatric disorder, including during the pendency of this claim, which was caused or aggravated by the Veteran's service, or a service-connected disability, or medications used to treat service-connected disability. The Board once again notes that there is an absence of psychiatric problems during the Veteran's periods of ACDUTRA or INACDUTRA. Further, while he doesn't necessarily argue such, there is no basis to establish service connection on a presumptive basis or based on continuity of symptomatology. Indeed, any current statement from the Veteran that his psychiatric disorder had its onset during a period of ACDUTRA or INACDUTRA is contradicted by past records in which he appears to have reported all of his existing medical conditions without mentioning any problems related to a psychiatric disorder. See AZ v. Shinseki, No.2012-7046, 2013 WL XXXXXXX, at *Y (Fed. Cir. Sept. 30, 2013) (recognizing the widely held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present); Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011). The report of the 1958 VA examination and 1972 records from the SSA include references to multiple disabilities but make no mention of a psychiatric disorder. There is likewise no competent medical opinion that links the Veteran's reported psychiatric disorder to his period of ACDUTRA or INACDUTRA or a service connected disorder. The VHA opinion is comprehensive and provides a more than adequate negative opinion on these questions. Indeed, the VHA reviewer's summary of the Veteran's records is detailed, and sets out the paucity of documentation that the Veteran manifested symptoms adequate to support the assigned diagnoses. The VHA reviewer's conclusion that it is less than likely that the Veteran currently has a psychiatric disorder which is related to his service or to a service-connected disability, or has manifested such a psychiatric disorder at any time during the pendency of this claim, is well-reasoned and sets forth several rationales supporting the conclusion. The Board finds that the preponderance of the probative and persuasive evidence establishes that the Veteran does not meet any criterion for service connection for a psychiatric disorder under any legal theory of entitlement to service connection. Consideration has been given to the Veteran's assertions that his psychiatric symptoms, including nervousness, are somehow related to his injuries in service or the service-connected disabilities. It is true that lay persons are competent to provide opinions on some medical issues. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, as to the specific issue in this case, the assignment of a diagnosis for or etiology for a psychiatric disorder falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). That is, although the Board readily acknowledges that Veteran is competent to report that he feels nervous or anxious or can't remember things, there is no indication that the Veteran is competent to etiologically link such symptoms to his service or the injury he incurred in service. The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. The credible evidence of record establishes that more than 10 years elapsed after the Veteran's service before he sought psychiatric evaluation. The record establishes that the Veteran's reports of symptoms have been inconsistent and, as the VHA reviewer noted, a lack of professional consensus at to an appropriate diagnosis. This evidence is, as discussed by the VHA reviewer, unfavorable to the Veteran's claim that he has a psychiatric disorder which may be linked to his service or to a service-connected disability. The preponderance of the probative and persuasive evidence is against the Veteran's claim for service connection for an acquired psychiatric disorder on any basis, to include as secondary to service-connected left foot disability. There is no reasonable doubt. 38 U.S.C.A. § 5107(b). The claim must be denied. 2. Claim for service connection for right knee or ankle disorder Service treatment records are negative for any complaints, treatment, or diagnosis of a disorder of the right lower extremity, to include the knee and ankle, during any period of ACDUTRA or INACDUTRA. The Veteran does not necessarily argue the contrary. The Veteran was afforded VA examination in August 1958. He did not report any complaint or disorder of the right ankle or right knees. Had he injured his right lower extremity that resulted in his left foot, the Board finds that it would have warranted mentioning such at that examination. Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011); Kahana v. Shinseki, 24 Vet. App. 428, 440 (2011) (Lance, J., concurring) (citing FED. R. EVID. 803(7) for the proposition that "the absence of an entry in a record may be evidence against the existence of a fact if such a fact would ordinarily be recorded"). Indeed, there is no notation that the Veteran reported any disorder or impairment of the right lower extremity to SSA when he applied for benefits in 1972, and there is no SSA record of report or complaint of right lower extremity impairment at the time of re-evaluation for benefits in 1981 or 1982. The lack of notation of any right lower extremity impairment in the first 25 years after the Veteran's service is unfavorable to the claim. VA outpatient treatment records dated in January 1985 reflect that the Veteran reported joint pain of multiple joints. There is, however, no specific notation of complaints of right ankle pain or right knee pain appears in the 1985 treatment notes, and no treatment of the ankles or knees was noted. The Veteran was given a soft insole for his left shoe in October 1985. In 1986, radiologic examination of the left foot disclosed spur formation at the plantar aspect, left foot, and Achilles tendon calcification. VA consultation in June 1986 showed that the Veteran had very little motion of the left ankle. He complained of left lower extremity pain. The Veteran sought an increased evaluation for left foot disability. There are no recorded complaints of right ankle pain or pain of either knee. In July 1987, the Veteran underwent radiologic examinations of the left knee and left ankle. There was a left plantar calcaneal spur and abnormality of the posterior aspect of the os calcis. There was full range of passive motion of the left ankle, but little active range of motion. The provider observed that the Veteran appeared anxious. The Veteran used a cane when walking. The report includes no reference to a right leg or right ankle complaint or abnormality. In February 1988, the Veteran testified at a hearing before the RO. The Veteran testified that he had severe left leg pain and could "barely" walk and was unable to stand for any period of time because of left foot pain. The Veteran did not discuss a right knee, right ankle, or right leg disorder. The Veteran submitted the report of a March 1992 private examination of the left lower extremity. No complaint or abnormality of the right lower extremity was noted. Records of VA hospitalization in 1996 include no reference to any complaint, treatment, or abnormality of the right knee, right ankle, or right lower extremity. During the period from 1996 to 2005, the Veteran received VA outpatient treatment, but the records do not reflect VA treatment for a complaint of a right leg disorder. No right leg disorder was recorded as part of the December 2002 VA examination of the left foot. Following the May 2005 claim for service connection for arthritis of both legs, the Veteran was afforded VA examination in June 2007. No complaints or findings related to the right lower extremity were noted. Radiologic examination of both ankles and feet in August 2006 was interpreted as showing "normal bony mineralization," normal preservation of joint spaces, and symmetry of the right and left feet expect for left hallux valgus. Thus, the x-ray findings are consistent with the service-connected left foot disability and with a normal right foot. This evidence is unfavorable to the claim, since it fails to show the claimed right ankle disorder. At the time of the March 2009 VA examination, the appellant reported to the examiner that he sought private treatment from Dr. M. for right knee and ankle pain and was treated with liniment and medications. The apparently incomplete private treatment records from Dr. M which are associated with the claims files discuss only the Veteran's left foot. The examiner who conducted VA examination of the right lower extremity in May 2009 concluded that the objective physical examination could not be completed because of the Veteran complained of severe pain on light touch. The Veteran had an antalgic gait, and reported right knee and ankle pain with standing or walking. The Veteran reported giving way, instability, pain, weakness, subluxation, and locking of the right ankle. Ranges of motion of the right ankle and right knee could not be completed due to the Veteran's complaints of pain. Radiologic examination disclosed no pathology of the right knee or right ankle. The VA examiner, in March 2009, opined that the right knee and ankle disabilities were less than likely related to the appellant's service-connected left foot disability. He reasoned that the right knee and right ankles are different anatomical structures from the left knee and ankle. The examiner concluded that, if there were any disorder of the right knee or right ankle, such disorder was not etiologically related to the Veteran's service-connected left foot disability. The examiner assigned a diagnosis of bilateral knee genu varus, but did not comment upon whether such was a congenital defect or disease, and if so, whether such was aggravated by the Veteran's service or his service-connected left foot disability. The examiner did not opine as to whether any right knee or right ankle disorders were aggravated (made permanently worse beyond the natural progression of the disease) by the appellant's service connected left foot disability. The Board Remanded this claim for additional development of the medical evidence. Radiologic examination of the right ankle conducted in conjunction with the October 2012 VA examination disclosed osteopenia (diminished bone density) of the right ankle, a spur at the right medial malleolus, and a small calcaneal spur. Radiologic examination of the knees showed bilateral arthritic changes of the knees, including the right knee. The examiner concluded that, since the Veteran's right knee was normal on radiologic examination in 2009, the changes found in 2012, when the Veteran was more than 75 years old, were due to aging, and were not due to the service-connected left foot or lumbar disabilities. 38 C.F.R. § 3.303. The examiner also opined that there was no aggravation of genu varus, a congenital condition, by the service-connected left foot disability or other service-connected disability, since there was no early onset of osteoarthritis. The examiner further opined that the Veteran's "current knee and ankle degenerative changes" were "related to the natural aging process." The Board finds the examiner's reasoning clear and persuasive. The Veteran's right knee and right ankle arthritis were not objectively shown prior to May 2005, when the Veteran submitted the claim on appeal. At that time, the Veteran was 70 years of age and had incurred the service-connected disability more than 45 years earlier. The fact that arthritis of the right knee and of the right ankle, to include the calcaneus, is now objectively manifested, when the Veteran is more than 75 years old, is consistent with the examiner's conclusion that the Veteran's current right lower extremity arthritis is due to aging and is less than likely due to a service-connected left foot disability, other service-connected disability, or aggravation of congenital genu varus by the service-connected left foot disability, other service-connected disability. The examiner's reasoning that arthritis which does not appear until 45 years after the Veteran's incurrence of a service-connected injury is not likely due to or accelerated by any service-connected disability, but, rather, is due to the aging process, is probative and persuasive. Given the foregoing, the Board finds that the competent evidence of record fails to establish an etiological relationship between the Veteran's degenerative joint disease of the right knee and/or ankle and any period of ACDUTRA or INACDUTRA or any service connected disorder. The negative medical opinions of record are unrefuted and found to be more than adequate in addressing the salient questions relating to this appeal. The Veteran's lay assertion as to the etiology of his arthritis has been considered but is outweighed by the opinions from VA's medical professionals. To be sure, he is more than competent to address the symptoms related to his right knee and ankle disorder but he lacks the competence to provide etiological opinions. Such requires a level of medical expertise that he does not possess. The Board acknowledges that the Veteran complained of right knee and right ankle pain for many years prior to diagnosis of arthritis on objective radiologic examination. The Veteran's earlier complaints of pain, without objective findings, and given the normal findings on radiologic examinations in 2006 and 2009, do not warrant additional medical development, even though the Veteran is competent to state that pain was present. Indeed, as noted, application of the presumption of service connection for arthritis and/or continuity of symptomatology is applicable in the present appeal. The preponderance of the probative and persuasive evidence is against the Veteran's claim for service connection for a right knee and/or right ankle on any basis, to include as secondary to service-connected left foot disability. There is no reasonable doubt. 38 U.S.C.A. § 5107(b). The claim must be denied. ORDER The appeal for service connection for an acquired psychiatric disorder, to include as secondary to service-connected left foot disability, is denied. The appeal for service connection for right knee and right ankle disorders, to include as secondary to service-connected left foot disability, is denied. ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs