Citation Nr: 1341964 Decision Date: 12/19/13 Archive Date: 12/31/13 DOCKET NO. 10-00 350A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for left knee disability 2. Entitlement to service connection for headaches. 3. Entitlement to service connection for sleep disorder. 4. Entitlement to service connection for hypertension. 5. Entitlement to service connection for left shoulder disability. 6. Entitlement to service connection for back disability. 7. Entitlement to service connection for skin condition. 8. Entitlement to service connection for brain tumor. 9. Whether new and material evidence has been submitted to reopen a claim of entitlement to service connection for bilateral flat feet, and if so, whether service connection is warranted. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran had active military service from October 1968 to September 1969 and subsequent service in the National Guard. This appeal comes to the Board of Veterans' Appeals (Board) from January and June 2009 decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran provided sworn testimony in support of his appeal during a hearing before the undersigned Acting Veterans Law Judge in August 2013; the hearing transcript has been associated with the file and has been reviewed. The Board has not only reviewed the Veteran's physical claims file but also the Veteran's file on the "Virtual VA" system to insure a total review of the evidence. In a January 2010 statement the Veteran contended he has memory loss due to service and in a May 2011 statement he contended he has a left ankle disability due to service. As both service connection issues have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ), the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. The issue of service connection for bilateral flat foot being remanded is addressed in the REMAND portion of the decision below and is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's left knee disability is not causally or etiologically related to service and arthritis did not manifest to a compensable degree within one year of his discharge. 2. The Veteran's left shoulder disability is not causally or etiologically related to service and arthritis did not manifest to a compensable degree within one year of his discharge. 3. The Veteran's back disability is not causally or etiologically related to service and arthritis did not manifest to a compensable degree within one year of his discharge. 4. The Veteran's meningioma is not causally or etiologically related to service. 5. The Veteran's headaches are not causally or etiologically related to service. 6. The Veteran's onychomycosis and tinea pedis is not causally or etiologically related to service. 7. The Veteran's sleep apnea is not causally or etiologically related to service. 8. The Veteran's hypertension is not causally or etiologically related to service and did not manifest to a compensable degree within one year of his discharge. 9. In May 1988 the RO denied service connection for bilateral flat feet. The Veteran did not timely appeal that decision and no new evidence pertinent to the claim was received by VA within one year from the date that the RO mailed notice of the determination to the Veteran. 10. New evidence received since the time of the final May 1988 rating decision relates to an unestablished fact necessary to grant service connection for bilateral flat feet and raises a reasonable possibility of substantiating the Veteran's claim. CONCLUSIONS OF LAW 1. The criteria for service connection for left knee disability have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.306, 3.307, 3.309 (2013). 2. The criteria for service connection for left shoulder disability have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.306, 3.307, 3.309 (2013). 3. The criteria for service connection for back disability have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.306, 3.307, 3.309 (2013). 4. The criteria for service connection for brain tumor have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.306, 3.307, 3.309 (2013). 5. The criteria for service connection for headaches have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2013). 6. The criteria for service connection for skin condition have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2013). 7. The criteria for service connection for hypertension have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2013). 8. The criteria for service connection for sleep disorder have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304 (2013). 8. The May 1988 rating decision denying service connection for bilateral flat foot is final. 38 U.S.C.A. § 7015 (West 2002); 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2013). 9. Evidence submitted to reopen the claim of entitlement to service connection for bilateral flat feet is new and material. 38 U.S.C.A. §§ 5108 (West 2002); 38 C.F.R. § 3.156 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2013). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). To establish service connection, there must be a competent diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252 (1999); see Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Service connection may also be granted on a presumptive basis for certain chronic diseases, including malignant brain tumors, arthritis, and cardiovascular-renal disease, if shown to be manifest to a degree of 10 percent or more within one year following a veteran's separation from active service. 38 U.S.C.A. §§ 1101, 1112, 1113 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2013). It is noted that in 38 C.F.R. § 3.309, the term cardiovascular-renal disease applies to combination involvement of the type of arteriosclerosis, nephritis, and organic heart disease, and that since hypertension is an early symptom long preceding the development of those diseases in their more obvious forms, a disabling hypertension within the one-year period following separation will be given the same benefit of service connection as any of the other chronic diseases listed in that Section. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. At his Board hearing in August 2013 the Veteran testified while in service he was pushed out of a helicopter that was approximately 10 feet above the ground. The Veteran testified that he believes his shoulder, back, knee, and headache problems were caused by that incident. The Veteran further testified that at the time of the fall the platoon medic told him he was knocked unconscious for about three minutes and when he regained consciousness a commanding officer asked whether he could walk around and when he was able to, he was told he was fine. He reported he later saw the company medic and was again told he was fine. He explained that he believes the incident was not documented because the commanding officer was known for wanting to keep a clean record. Although the Veteran is competent to report falling from a helicopter and losing consciousness, the Board finds his description of the incident is not credible. The Board first notes the lack of service treatment records referencing the incident, particularly the fact that the Veteran was knocked unconscious, despite the fact that the Veteran contends he was seen by two medics. Further, the service treatment records show no subsequent treatment for any of the injuries the Veteran claims to have incurred. At the time of his discharge from service the Veteran himself also denied injury to the body parts he now claims he injured in the fall. He also denied a history of head injury at that time. Finally, the Veteran's descriptions of the incident in connection with his claim have varied, with him reporting being knocked out for three minutes at his Board hearing, for six to eight minutes at his September 2009 DRO hearing, and for three to six minutes in an October 2009 statement. The above factors all create doubt as to the credibility of the Veteran's current recollection of the claimed helicopter fall, particularly with regard to being knocked unconscious as a result. The Board also notes that Veteran testified at his Board hearing that he did not have a separation examination at the time of his discharge from service. However, the Board finds that the record contains a detailed December 1969 discharge examination report. The examination report reflects that on clinical evaluation the Veteran's upper extremities, lower extremities, and skin were all found to be normal, as was his neurologic examination. On the accompanying report of medical history form the Veteran did not report frequent or severe headache; history of head injury; skin disease; high or low blood pressure; arthritis or rheumatism; bone, joint, or other deformity; painful or trick shoulder; recurrent back pain; trick or locked knee; frequent trouble sleeping; or frequent or terrifying nightmares. Notably, the Veteran did report a variety of other conditions. Left Knee Service treatment records reflect that in November 1968 while still in basic training the Veteran reported bilateral knee pain, stating that he has had knee weakness since childhood. In December 1968 the Veteran complained of mild knee pain and swelling. At his Board hearing, the Veteran testified he first had problems with his left knee in May 1969 shortly before leaving service after falling from a helicopter. However, he said he did not seek medical treatment for his knee prior to leaving service or for the next 15 to 20 years. He said when he did seek treatment from a private physician he was told there was no cartilage under the knee cap. He got injections to replace the cartilage. Currently, the Veteran said his only treatment is taking pain medication. He reported his only symptom is pain. The Veteran underwent a VA examination in November 2009. The examiner diagnosed left knee strain, noting the Veteran reported a previously done private x-ray showed degenerative joint disease, but that those reports were not available for review. The examiner opined that the Veteran's knee condition is less likely than not caused by the Veteran's service to include his claimed fall from a helicopter. The examiner noted that a knee injury was not noted on the Veteran's separation examination or within a year of his separation from service. The Board finds that the evidence weighs against finding that the Veteran's current knee condition is related to his service. No service treatment records support the Veteran's contention that he injured his knee in a helicopter fall shortly before his discharge from service. Although the Veteran did report knee pain shortly after his entrance into service, subsequent records do not reflect any ongoing knee pain. Further, the Veteran's own statement at the time of his discharge in which he denied knee problems and the clinical evaluation in which the Veteran's lower extremities were found to be normal both provide highly probative evidence against finding that the Veteran's current knee condition was incurred in service. Further, the November 2009 VA examiner opined that the Veteran's current knee condition is less likely than not related to his service. No contrary expert medical opinion is of record. The Veteran has offered his own lay opinion that his knee condition is related to his service, specifically his claimed helicopter fall. However, the Board finds that the Veteran is not competent as a lay person to offer such a medical etiology opinion on a complex medical question such as the etiology of degenerative joint disease. To the extent that the Veteran's statement that he has been diagnosed with degenerative joint disease (DJD) is credible, the Board further finds that the evidence does not show that any DJD of his left knee manifest to a compensable degree within one year of service. The Veteran himself has testified that he sought no treatment for his knee until 15 to 20 years after service. As the preponderance of the evidence is against the Veteran's claim for service connection for left knee condition, the benefit of the doubt doctrine does not apply, and the claim must be denied. Left Shoulder and Back The Veteran has also contended his left shoulder and back disabilities are a result of his claimed helicopter fall in service. The Veteran testified he sought medical treatment for both his shoulder and back a couple years after his discharge from service. He said a back x-ray showed ruptured discs and he was prescribed pain medication. In September 1997 he said he had surgery to replace and repair discs. He stated his only treatment for his shoulder has been taking pain medication. The Veteran was afforded a VA examination on both conditions in November 2009. A shoulder x-ray showed moderate degenerative changes of the left acromioclavicular joint and atherosclerosis in the left shoulder. The examiner diagnosed degenerative joint disease and opined it is less likely as not caused by the Veteran's service to include his claimed fall from a helicopter. With regard to the back, the VA examiner diagnosed lumbar strain and also noted the Veteran reported a previous x-ray showed degenerative joint disease, although the x-ray was not available for review. The examiner opined the Veteran's back condition was not caused by his service, to include his claimed fall from the helicopter. As a rationale for his opinion, the examiner noted the lack of documentation of a left shoulder or back injury in service, on discharge from service, or within 12 months of leaving service. The Board finds that the evidence weighs against finding that the Veteran's current shoulder and back conditions are related to his service. Service treatment records do not reflect any complaints of or treatment for either his back or shoulder in service. Further, on his report of medical history at the time of his discharge the Veteran himself denied a painful shoulder or recurrent back pain problems. In addition, on examination at the time of discharge the Veteran's upper extremities were found to be normal. The above evidence provides highly probative evidence against finding that the Veteran's current left shoulder and back conditions were incurred in service. Further, the November 2009 VA examiner opined that neither condition is related to the Veteran's service. No contrary expert medical opinion is of record. The Veteran has offered his own lay opinion that both conditions are related to his service, specifically his claimed helicopter fall. However, the Board finds that the Veteran is not competent as a lay person to offer such a medical etiology opinion as to a complex medical question such as the etiology of degenerative joint disease. The Board further finds that the evidence does not show DJD in the Veteran's shoulder or back manifest to a compensable degree within one year of his discharge from service. No medical records are of record from that time showing such a diagnosis. As the preponderance of the evidence is against the Veteran's claim for service connection for left shoulder and back conditions, the benefit of the doubt doctrine does not apply, and the claims must be denied. Brain Tumor In an August 2009 letter the Veteran's private physician stated that an October 2005 MRI showed a mass at the base of the Veteran's skull suggestive of an meningioma. The doctor opined that the tumor has been present "for a very long time and could possibly have been present as long as 30 or 40 years ago." The Veteran testified he has not had the tumor removed and it is still present. In statements, the Veteran has suggested the tumor could have been caused by his claimed helicopter fall in service and that his private physician's estimate of how long the tumor had been present could put its incurrence at the time of service. Although the evidence reflects that the Veteran has a current meningioma that may have been present for decades, the weight of the evidence does not show that tumor was incurred in or as a result of the Veteran's service, to include his claimed helicopter fall. Further, the evidence does not reflect that the tumor is either malignant or manifest to a compensable degree within one year of the Veteran's discharge from service, therefore presumptive service connection under 38 C.F.R. § 3.307 is not applicable. The Veteran's meningioma was first diagnosed in 2005, more than three decades after service. The private physician's estimate when the meningioma first developed encompasses a wide number of years that would include time before service, in service, and after service. The physician offered no rationale as to the cause of the tumor. The Court has held that "a medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Here, that analysis is lacking. More significantly, the physician's use of the words "could have" makes the opinion speculative. See Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus). See also Warren v. Brown, 6 Vet. App. 4, 6 (1993) (doctor's statement framed in terms such as "could have been" is not probative). Although the Veteran himself has opined that his claimed helicopter fall could have caused the tumor, he does not describe recurrent symptoms of a brain tumor since service, and the Board finds he is not competent as a lay person to offer such an opinion on a complex medical question and thus his statements are not probative evidence that support his claim. As a preponderance of the evidence is against finding that the Veteran's meningioma was either incurred in or caused by service, the benefit of the doubt doctrine dos not apply, and his claim for service connection must be denied. Headaches The Veteran testified at his Board hearing that he first sought treatment for headaches one or two months after leaving service from a primary care physician. He said he currently is treated for the condition at the VA, where he has been prescribed butabatol. He stated he gets headaches twice a day. A private treatment record reflects that in April 2002 the Veteran sought treatment for a "two month history" of headaches and nasal congestion. A CT scan was normal. An October 2005 MRI showed a mass at the base of the Veteran's skull suggestive of an meningioma. The VA examiner opined that the Veteran's headaches were not caused by the Veteran's service to include his claimed fall from a helicopter. The examiner noted a 2002 VA treatment note reflecting a complaint of headaches for two months and the lack of additional documentation showing reported headaches other than a November 2005 note and a 2009 psychiatry note. The examiner also noted the lack of documentation of headaches in service, on discharge from service, and within 12 months of leaving service. The Board finds that the evidence weighs against finding that the Veteran has a headache condition related to his service. Service treatment records do not reflect any complaints of headaches. Further, on his report of medical history at the time of his discharge the Veteran denied frequent or severe headaches, providing highly probative evidence against his contention that his headache condition originated in service. Further, a 2002 VA treatment note suggests a recent onset of headaches, not a more than 30 year history. In addition, the November 2009 VA examiner opined that the Veteran's headache condition is not related to his service. No contrary expert medical opinion is of record. To the extent that the Veteran has suggested his headaches are secondary to his brain tumor, the Board notes that it has denied service connection for the tumor, therefore, the Veteran is not entitled to secondary service connection on that basis. As the preponderance of the evidence is against the Veteran's claim for service connection for headache condition, the benefit of the doubt doctrine does not apply, and the claim must be denied. Skin Condition The Veteran testified at his Board hearing that he first experienced fungus on his feet during Vietnam and has had it ever since. He said he was given foot powder to use in Vietnam. In the Veteran's original claim he also contends he has a rash around his neck and another body part that started in service. Although the Veteran is competent to report the existence of a skin condition and its duration, in this case, the Board finds that the evidence weighs against finding that the Veteran's current skin condition is related to his service. Specifically, service treatment records reflect no complaints of or treatment for foot fungus. In addition, the Veteran reported no skin diseases on his report of medical history form on discharge and his skin was found normal on his discharge examination. Both suggest that the Veteran has not had a skin condition that has existed since service. While the November 2009 VA examiner diagnosed the Veteran as currently having onychomycosis and tinea pedis, the examiner further opined that the conditions are less likely than not caused by service. Therefore, the Board finds that the only expert medical opinion in evidence supports that that Veteran's current skin conditions are not related to his service. Further, the Veteran's own statements at discharge and his discharge examination suggest his current contention that he has had a fungal condition since service is not credible. As the preponderance of the evidence is against the Veteran's claim for service connection for a skin condition, the benefit of the doubt doctrine does not apply, and the claim must be denied. Hypertension The Veteran's VA treatment records reflect that he was diagnosed with benign hypertension in 2010. The Veteran testified at his Board hearing that he was first diagnosed with hypertension by a private physician about two years after his discharge from service. He stated that he experienced dizziness while in service that he thought might have been a symptom of high blood pressure but was not checked while he was in service. At his DRO hearing the Veteran suggested that his hypertension could be due to the salt tablets he was told to eat while in advanced individual training. The Veteran's service treatment records from active duty reflect no diagnosis or complaints of hypertension. On his December 1969 discharge examination the Veteran was noted to have a blood pressure reading of 105/58. An April 1980 National Guard record reflects that the Veteran was checked for high blood pressure. A reading of 162/100 was taken with a second reading of 130/90 taken after 15 minutes of rest. He was recommended to see his private physician. Although the evidence shows the Veteran has a current diagnosis of hypertension, it does not support that the Veteran's hypertension was incurred in or caused by service or that it manifest to a compensable degree within one year of his discharge from active service. The first record of a hypertension diagnosis in the medical records is not until 2010, four decades after the Veteran's discharge from active service. Although there was a suggestion in April 1980 that the Veteran had experienced high blood pressure, the evidence is not sufficient to show that the Veteran had hypertension that manifest to a compensable degree within one year of his discharge from service. Notably, the Veteran's blood pressure reading done at his discharge examination does not reflect high blood pressure. Therefore, the Board finds a preponderance of the evidence is against finding that the Veteran's hypertension was incurred in or manifest to a compensable degree within one year of his discharge from active service. Although service connection may also be awarded for a disease or injury incurred during a period of active duty for training (ACDUTRA), including full-time duty with the Army National Guard of any state, the evidence does not show and the Veteran has not contended that his hypertension was incurred during a period of ACDUTRA. See 38 U.S.C.A. §§ 101(2), (22), (24), 1110 (West 2002); 38 C.F.R. § 3.6(c) (2013); Acciola v. Peake, 22 Vet. App. 320, 324 (2008). Further, there is no competent medical opinion evidence suggesting the Veteran's current hypertension was caused by his active duty service or any event therein, to include eating salt tablets. There is no expert medical opinion as to the cause of the Veteran's hypertension. Although the Veteran himself has opined it could have been caused by his service, specifically eating salt tablets, the Board finds his opinion is not probative as he is not competent as a lay person to opine as to the etiology of a medical condition such as hypertension. The Board notes that Veteran is competent to report a readily observable symptom such as dizziness during service; however, he is not competent to connect that symptom to the onset of his hypertension. As the preponderance of the evidence is against the Veteran's claim for service connection for hypertension, the benefit of the doubt doctrine does not apply, and the claim must be denied. Sleep Disorder The Veteran testified he first experienced trouble sleeping about two months after he arrived in Vietnam. He stated that they were always on the move, disrupting his sleep, and began having nightmares of combat. VA treatment records show the Veteran was diagnosed with obstructive sleep apnea in May 2009. The Board notes that the Veteran is currently service-connected for posttraumatic stress disorder and to the extent that his sleep difficulties are a symptom of that condition he is not entitled to separate compensation. See 38 C.F.R. § 4.14 (2013). However, the Veteran may be entitled to service connection for sleep apnea, which is a separate disability. The evidence, however, does not support that the Veteran's sleep apnea was incurred in or caused by service. The Veteran was not diagnosed with sleep apnea until 40 years after service. Further, no medical opinion evidence is of record suggesting a connection between the Veteran's sleep apnea and his service. As the preponderance of the evidence is against the Veteran's claim for service connection for a sleep disorder, the benefit of the doubt doctrine does not apply, and the claim must be denied. Flat Feet The RO denied service connection for bilateral flat foot in May 1988. The Veteran did not file a notice of disagreement and no new evidence pertinent to the claim was received by VA prior to the expiration of the appeal period. In addition, VA has not received or associated with the claims file any relevant official service department records that existed and had not been associated with the claims file at the time of the May 1988 decision. Therefore, the May 1988 decision is final. 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 3.156(b) and (c), 20.302, 20.1103 (2013). A previously denied claim may be reopened by the submission of new and material evidence. 38 U.S.C.A. § 5108; 38 C.F.R. 3.156. The Board is neither required nor permitted to analyze the merits of a previously denied claim if new and material evidence has not been submitted. Butler v. Brown, 9 Vet. App. 167, 171 (1996). New evidence means existing evidence not previously submitted to VA. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a) (2013). The Court has interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." Shade v. Shinseki, 24 Vet. App 110 (2010). In Hodge v. West, 155 F.3d 1356, 1363 (Fed. Cir. 1998), the United States Court of Appeals for the Federal Circuit noted that new evidence could be sufficient to reopen a claim if it could contribute to a more complete picture of the circumstances surrounding the origin of a claimant's injury or disability, even where it would not be enough to convince the Board to grant a claim. In determining whether evidence is new and material, the credibility of the evidence is generally presumed. Justus v. Principi, 3 Vet. App. 510, 512-513 (1992). The RO denied the Veteran's original claim in 1988 because the Veteran failed to report for a VA examination and the service treatment records, the only evidence of record, were not sufficient evidence to grant his claim. In connection with his claim to reopen, the Veteran testified at an August 2013 Board hearing. He stated that during advanced individual training he noticed his feet getting flatter and that he had lost his arch. In statements he suggested the condition was due to wearing combat boots, and he asserted the condition had continued since service. The Board finds that presumed credible the Veteran's statements are sufficient to reopen the claim. In short, they suggest that a pre-existing bilateral flat foot disability was permanently worsened by his active military service. The Board thus finds that new and material evidence has been submitted to reopen the issue of entitlement to service connection for flat feet since the 1988 rating decision. On this basis, the issue of entitlement to service connection for flat feet is reopened. Duties to Notify and Assist Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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 C.F.R. § 3.159(b)(1). Such notice should also address VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). In the context of a claim to reopen, the VA must also provide notice that describes what evidence is necessary to show the element or elements required to establish service connection that were found insufficient in the previous denial. Kent v. Nicholson, 20 Vet. App. 1 (2006). Notice letters were sent to the Veteran in January 2008, October 2008, and April 2009, prior to the initial adjudications of the claims. The letters informed the Veteran of what information and evidence must be submitted to substantiate the claims, including a description of what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. He was also advised to inform VA of any additional information or evidence that VA should have, and to submit evidence in support of the claim to the RO. The content of the letters complied with the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b). While the letters did not articulate the basis of the prior denial of the claim for service connection for flat foot, the Veteran was advised to submit evidence showing that flat foot was incurred in service. During his testimony before the undersigned, he demonstrated actual knowledge of the criteria to reopen the previously denied claim. Thus, the Board will not remand this matter for additional notice. Further, although none of the letters specifically noted the Veteran's claim for a left knee disorder, the Board also finds the Veteran was given notice of what was required to substantiate a claim for service connection and demonstrated actual knowledge of the criteria at the Board hearing. The duty to notify has been satisfied as to all claims. The undersigned Acting VLJ who conducted the August 2013 hearing also complied with the duties to fully explain the issues on appeal and suggest the submission of evidence that may have been overlooked. 38 C.F.R. 3.103(c)(2); Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Veteran was assisted at the hearing by an accredited representative from the Disabled American Veterans, and the Acting VLJ and the representative asked questions regarding the nature and etiology of the Veteran's claimed conditions. In addition, the Acting VLJ sought to identify any pertinent evidence not currently associated with the claims file that might have been overlooked or was outstanding that might substantiate the claim. Neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2) or identified any prejudice in the conduct of the Board hearing. VA also has a duty to assist the Veteran with the development of facts pertinent to the appeal. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). This duty includes the obtaining of "relevant" records in the custody of a federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1). VA will also provide a medical examination if such examination is determined to be "necessary" to decide the claim. 38 C.F.R. § 3.159(c)(4). The Board finds that all necessary development has been accomplished. The RO has obtained the Veteran's service treatment records, VA treatment records, and private treatment records identified by the Veteran. The Veteran also submitted lay statements. Neither the Veteran nor his representative has identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claim that has not been obtained. The Veteran was afforded VA medical examinations with respect to his knee, shoulder, back, headaches, and skin condition in November 2009. The examiner, a medical professional, obtained an accurate history, listened to the Veteran's assertions, and provided etiology opinions. Therefore, the Board finds that the examinations are adequate and contain sufficient information to decide the issues on appeal. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The Veteran was not afforded a VA examination with respect to his claimed hypertension, sleep disorder, or brain tumor, but the Board finds none is required. In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained with respect to a veteran's claim for benefits, there are four factors for consideration. These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d) and 38 C.F.R. § 3.159(c)(4). With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence "indicates" that there "may" be a nexus between the current disability or symptoms and the veteran's service. The types of evidence that "indicate" that a current disability "may be associated" with military service include, but are not limited to, medical evidence that suggests a nexus but is too equivocal or lacking in specificity to support a decision on the merits, or credible evidence of continuity of symptomatology such as pain or other symptoms capable of lay observation. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Federal Circuit has addressed the appropriate standard to be applied in determining whether an examination is warranted. In Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) and Colantonio v. Shinseki, 606 F.3d 1378 (Fed. Cir. 2010), the Federal Circuit held that while there must be "medically competent" evidence of a current disability, "medically competent" evidence is not required to indicate that the current disability may be associated with service. Colantonio, 606 F.3d at 1382; Waters, 601 F.3d at 1277. On the other hand, a conclusory generalized lay statement suggesting a nexus between a current disability and service would not suffice to meet the standard of subsection (B), as this would, contrary to the intent of Congress, result in medical examinations being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters, 601 F.3d at 1278-1279. Here, as the only evidence that the Veteran's hypertension, sleep apnea, and brain tumor are related to his military service are his own conclusory generalized lay statements, which are unsupported by even speculative medical evidence. Accordingly, the Board finds that referral for a VA medical examination is not warranted. 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, 16 Vet. App. 183. ORDER Service connection for left knee disability is denied. Service connection for headache disability is denied. Service connection for sleep condition is denied. Service connection for skin condition is denied. Service connection for hypertension is denied. Service connection for back disability is denied. Service connection for brain tumor is denied. New and material evidence having been submitted, the Veteran's claim for entitlement to service connection for flat feet is reopened and, to that extent only, the appeal is granted. REMAND A remand is required in this case to ensure that there is a complete record upon which to decide the issue of entitlement to service connection for flat feet, so that the Veteran is afforded every possible consideration. The Board notes that pes planus is noted on the Veteran's September 1968 entrance examination. The Veteran has testified that he lost arches in both feet during service. The Veteran is competent to report such a condition as it is capable of lay observation. However, there is not sufficient evidence to support a decision on the merits. In short, there is a question as to whether a preexisting flat foot condition was permanently aggravated by his active military service. Under these circumstances, the Veteran should be provided a VA examination and opinion addressing whether he has a flat foot condition that was aggravated by his service. See 38 C.F.R. § 3.159(c)(4); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate examiner to determine the nature of his claimed flat feet condition. The claims file and a copy of this remand must be made available to and reviewed by the examiner in conjunction with the examination. Following a review of the claims file, to include service and post-service medical records, and the examination results, the examiner is requested to determine whether the Veteran has flat feet. If such disability is diagnosed, the examiner is requested to opine as to whether the condition was permanently aggravated by the Veteran's service such that there was a permanent increase in severity of the condition during service on the basis of the manifestations prior to, during, and subsequent to service. 2. After completing the above development, and any other development deemed necessary, readjudicate the issue on appeal. If the benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board for appellate review, after the Veteran has had an adequate opportunity to respond. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ M. TENNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs