Citation Nr: 1322667 Decision Date: 07/16/13 Archive Date: 07/24/13 DOCKET NO. 08-38 877 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a respiratory disorder, to include as a result of in-service asbestos exposure. 2. Entitlement to service connection for a left ankle disorder. 3. Entitlement to service connection for a heart disorder, to include as secondary to posttraumatic stress disorder (PTSD). WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD R. Casadei, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, served in the U.S. Navy from February 1948 to January 1952, and in the U.S. Coast Guard from November 1955 to October 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2008 rating decision by the Department of Veterans Affairs (VA) "Tiger Team," located at the Regional Office (RO) in Cleveland, Ohio, which denied service connection for a respiratory disability, a right ankle disorder, a right shoulder disorder, a left ankle disorder, coronary artery disease (heart disorder), to include as secondary to PTSD, and hypertension; denied an increased rating in excess of 50 percent for PTSD; and denied individual unemployability due to service-connected disabilities (TDIU). Due to the Veteran's place of residence, the RO in Roanoke, Virginia, assumed jurisdiction. In a September 2008 Notice of Disagreement (NOD), the Veteran specifically expressed disagreement only with the Tiger Team's decisions regarding the respective claims for service connection for a respiratory disorder, a right ankle disorder, a right shoulder disorder, a left ankle disorder, and coronary artery disease, to include as secondary to PTSD, and an increased rating in excess of 50 percent for PTSD. As the Veteran did not file a timely NOD indicating disagreement with the Tiger Team's respective denials of service connection for hypertension and a TDIU in a timely fashion, these claims are not in appellate status, and are not before the Board. 38 U.S.C.A. § 7105 (West 2002). In November 2008, the Roanoke RO issued a Statement of the Case (SOC). Subsequently, in December 2008, the Veteran filed a Substantive Appeal to the Board, specifically limiting his appeal to the respective issues of service connection for a respiratory disorder, a right ankle disorder, a right shoulder disorder, a left ankle disorder, and coronary artery disease, to include as secondary to PTSD. As the Veteran did not appeal the Tiger Team's denial of an increased rating in excess of 50 percent for PTSD in a timely fashion, the issue is not in appellate status, and is not before the Board. In July 2010, the Veteran testified at a hearing before the undersigned Veterans Law Judge, seated at the Roanoke RO (Travel Board hearing). A transcript of that hearing was procured and associated with the claims file. In an October 2010 Board Decision and Remand, the Board denied service connection for a right ankle disorder. As the Veteran did not appeal the grant of service connection for a right ankle disorder in a timely fashion, the Board decision became final. The issue of service connection for a right ankle disorder is no longer in appellate status and is not before the Board. 38 U.S.C.A. § 7104 (West 2002 & Supp. 2012); 38 C.F.R. § 20.1100 (2012). In October 2011, the Board remanded the claims on appeal, in addition to the claim for service connection for a right shoulder disorder, for further evidentiary development of requesting outstanding private treatment records, Office of Personnel Management records, and to obtain VA examinations for the Veteran's purported pulmonary, ankle, shoulder, and heart disabilities. The claims were readjudicated in a February 2013 supplemental statement of the case. For the reasons discussed below, the Board concludes that that the Board's remand orders on the issues of service connection for a respiratory disorder and left ankle disorder have been substantially complied with and it may proceed with a decision on these issues. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). Regarding the claim for service connection for a right shoulder disorder, the RO granted service connection for right shoulder bursitis with an evaluation of 10 percent, effective October 20, 2007. See April 203 rating decision. Therefore, as the April 2013 rating decision represents a full grant of the benefit sought on appeal, the issue of service connection for a right shoulder disorder is no longer in appellate status. The record contains two VA Forms 21-22 (Appointment of Claimant's Representative). The first, dated March 2007, appoints Disabled American Veterans as the representative. The second VA Form 21-22a, which is undated, but appears to have been received by VA in April 2013, appoints S. Sexton, an accredited attorney, as the representative. In light of this discrepancy, the Board requested that the Veteran clarify the matter. The Board's May 2013 letter informed the Veteran that, if no response or clarification of representation was received within 30 days, the Board would assume that the Veteran was representing himself. The Board has not received a response from the Veteran. As no updated appointment of representation has been received by the Board, it is assumed that the Veteran is representing himself at this time. The issue of service connection for a heart disorder, to include as secondary to PTSD, 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. 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). FINDINGS OF FACT 1. The Veteran was exposed to asbestos in service. 2. The Veteran does not have a currently diagnosed respiratory disability, to include asbestosis. 3. Post-service treatment records reveal diagnoses of a left ankle sprain and left foot plantar calcaneal spur. 4. The Veteran did not sustain a left ankle injury during service. 5. The currently diagnosed left ankle disorder is not related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a respiratory disorder, to include as a result of in-service asbestos exposure, have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). 2. The criteria for service connection for a left ankle disorder have not been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), the United States Department of Veterans Affairs (VA) has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). VA has a duty to notify a claimant of any information and evidence needed to substantiate and complete a claim. 38 U.S.C.A. §§ 5102, 5103. In order to meet the requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), VCAA notice must (1) inform the claimant about the information and evidence necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. VCAA notice should be provided to a claimant before the initial unfavorable agency of original jurisdiction (AOJ) decision on a claim. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (Court) held in Dingess v. Nicholson, 19 Vet. App. 473 (2006), that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include (1) the veteran's status; (2) the existence of a disability; (3) a connection between the veteran's service and the disability; (4) the degree of disability; and (5) the effective date of the disability. The Court held that upon receipt of an application for a service connection claim, 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) require VA to review the information and the evidence presented with the claim, and to provide the claimant with notice of what information and evidence not previously provided, if any, will assist in substantiating or is necessary to substantiate the elements of the claim as reasonably contemplated by the application. Id. at 486. This notice must also inform the veteran that a disability rating and an effective date for the award of benefits will be assigned if service connection is granted. Id. A December 2007 VCAA notice substantially satisfied the provisions of 38 U.S.C.A. § 5103(a). In this letter, the RO informed the Veteran about the information and evidence not of record that was necessary to substantiate his claims; the information and evidence that VA would seek to provide; the information and evidence the Veteran was expected to provide; and the information required by Dingess regarding the establishment of ratings and effective dates. Also, there is no prejudice in issuing a final decision because the preponderance of the evidence is against the claims for service connection and, therefore, no rating or effective dates will be assigned. The Board further finds that all necessary assistance has been provided to the Veteran. The evidence of record indicates that VA acquired the Veteran's VA, private, and service treatment records to assist with the claims. The Veteran was also afforded VA examinations regarding his claim for service connection for a respiratory disorder and left ankle disorder in October 2010 and January 2013. To that end, 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). In June 2012, the Board remanded the case in efforts to obtain supplemental VA opinions to assist in determining the diagnoses and etiology of the Veteran's disorders. As will be discussed in more detail below, the Board finds that the January 2013 VA opinions are adequate as they considered all of the pertinent evidence of record and provided a complete rationale for the opinions stated. In view of the foregoing, the Board finds that VA has fulfilled its duty to notify and assist the Veteran in the claims under consideration. Adjudication of the claims at this juncture, without directing or accomplishing any additional notification and/or development action, poses no risk of prejudice to the Veteran. Bernard v. Brown, 4 Vet. App. 384, 394 (1993). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The respiratory and left ankle conditions discussed herein are not considered chronic diseases as listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) does not apply. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Generally, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). When all the evidence is assembled, 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 a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In rendering a decision on appeal the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert, 1 Vet. App. at 57. Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005) (rejecting medical opinions that did not indicate whether the physicians actually examined the veteran, did not provide the extent of any examination, and did not provide any supporting clinical data). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment, including by a veteran. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner's opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). Service Connection for Respiratory Disorder The Veteran contends that he was exposed to asbestos while working in a ship's engine room during service in the Navy. At the July 2010 Board hearing, the Veteran testified that, as part of his duties, he had to replace asbestos-laden pipes aboard ships. He recalled that, often, he would awaken in the morning to find his blanket covered with asbestos. Although he reported that he currently was not being treated for a respiratory disability, he stated that he would experience symptoms of pneumonia twice a year. See July 2010 Hearing Transcript, pages 3-7. There is no specific statutory guidance with regard to asbestos-related claims, nor has the VA Secretary promulgated any specific regulations in regard to such claims. However, VA has issued a circular on asbestos-related diseases. DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988) provides guidelines for considering compensation claims based on exposure to asbestos. The information and instructions from the DVB Circular were included in the VA Adjudication Procedure Manual, M21-1 (M21-1), Part VI, § 7.21. In December 2005, M21-1, Part VI was rescinded and replaced with a new manual, M21-1MR, which contains the same asbestos-related information as M21-1, Part VI. The Court has held that VA must analyze an appellant's claim to entitlement to service connection for asbestosis or asbestos-related disabilities under the administrative protocols under the DVB Circular guidelines. See Ennis v. Brown, 4 Vet. App. 523 (1993); McGinty v. Brown, 4 Vet. App. 428 (1993). Subpart ii of M21-1MR Part IV lists some of the major occupations involving exposure to asbestos including mining, milling, work in shipyards, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, manufacture and installation of roofing and flooring materials, asbestos cement and pipe products, and military equipment. High exposure to respirable asbestos and a high prevalence of disease have been noted in insulation and shipyard workers, and this is significant considering that, during World War II, U.S. Navy veterans were exposed to chrysotile, amosite, and crocidolite that were used extensively in military ship construction. Furthermore, it was revealed that many of these shipyard workers had only recently come to medical attention because the latent period for asbestos-related diseases varies from 10 to 45 or more years between first exposure and development of disease. M21-1MR, Part IV Subpart ii, Chapter 2, Section C, Topic 9, see also M21- 1MR Part IV, Subpart ii, Chapter 1, Section H, Topic 29. VA's Manual 21-1MR, Part IV, subpart ii, Chapter 2, Section C in essence acknowledges that inhalation of asbestos fibers can result in fibrosis and tumors, and produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, and cancer of the lung, gastrointestinal tract, larynx, pharynx and urogenital system (except the prostate), with the most common resulting disease being interstitial pulmonary fibrosis (asbestosis). With respect to claims involving asbestos exposure, VA must determine whether or not military records demonstrate evidence of asbestos exposure during service, develop whether or not there was pre-service and/or post-service occupational or other asbestos exposure, and determine whether there is a relationship between asbestos exposure and the claimed disease. M21-1MR, Part IV, Subpart ii, Chapter 1, Section H, Topic 29; DVB Circular 21-88-8, Asbestos-Related Diseases (May 11, 1988). It should be noted that the pertinent parts of the Manual guidelines on service connection in asbestos-related cases must be considered by the Board in adjudicating asbestos-related claims. See VAOPGCPREC 4-2000. The Board points out that the Manual provisions do not create a presumption that a veteran was exposed to asbestos in service. See Dyment v. West, 13 Vet. App. 141 (1999), aff'd, Dyment v. Principi, 287 F. 3d 1377 (Fed. Cir. 2002). It should also be noted that for many asbestos-related diseases, the latency period varies from ten to forty-five or more years between first exposure and development of disease. M21-1MR at IV.ii.2.C.9.d. The Board finds that the Veteran was likely exposed to asbestos during active duty service. In various lay statements, the Veteran reported that he was exposed to asbestos during service; specifically, that he was exposed to asbestos while serving aboard ships. Although the Veteran's service treatment records are negative for asbestos-related disease or any mention of asbestos exposure, service personnel records reflect that the Veteran's military duties included service as a boilerman, which likely would have required him to perform activities exposing him to asbestos during service, including manufacturing and servicing equipment. See VA Adjudication Procedure Manual, M21-1, Part VI, para. 7.21. The Board notes that VA regulations do not provide a presumption of service connection for asbestos exposure claims. Next, after a review of all the evidence, lay and medical, the Board finds that the weight of the evidence of record demonstrates that the Veteran does not have a current respiratory disability. In this regard, service treatment records are negative for complaints, treatment, or diagnosis of any respiratory disorders. In an August 1966 report of medical examination, dated one year prior to service separation, clinical evaluation revealed normal lungs and chest. Post-service VA treatment records reveal that the Veteran was diagnosed with bronchitis in September 1986, was noted to have a cough in July 1987, and diagnosed with acute bronchitis in November 2005 and January 2007. Acute means "having a short and relatively severe course." See Dorland's Illustrated Medical Dictionary 24 (32nd ed. 2012). By contrast, chronic, in the general medical sense, is defined as "persisting over a long period of time." See Dorland's Illustrated Medical Dictionary 359 (32nd ed. 2012); Walker v. Shinseki, 708 F.3d 1331, No. 2011-7184, 2013 WL 628429 (Fed. Cir. Feb. 21, 2013) (generally discussing the meaning of "chronic" disability when not referring to a presumptive disease). Further, a January 2007 VA treatment note also reveals that the Veteran had "community acquired pneumonia" and the right lung base close to the diaphragm contained a small calcified density; however, in a March 2007 VA treatment note, the VA doctor noted that the bronchitis was most likely viral and the Veteran was recovering from acute bronchitis (resolving). In a later March 2007 VA treatment record, it was noted that the Veteran's cough was better and the lungs were clear. In an October 2010 VA treatment record, pulmonary function test (PFT) results were normal and the VA doctor noted no findings of asbestosis. The Board finds that, although respiratory conditions were noted after service separation, acute bronchitis and pneumonia resolved without residuals. Further, post-service VA treatment records revealed that the Veteran's lungs were clear in November 2002, February 2003, October 2003, May 2004, April 2005, October 2005, May 2006, December 2006, January 2008, March 2008, and April 2008. In February 2007, PFT results were normal and no change was noted from an earlier July 2000 PFT. The Board finds that this evidence demonstrates that the diagnosed post-service respiratory conditions (acute bronchitis and pneumonia) resolved with no residual disability. The evidence weighing in favor of a chronic respiratory disorder includes a report from Dr. R.B. dated November 2000. Upon examination, the doctor noted that the lungs were clear and PFT indicated normal function. Upon review of chest x-ray results, the doctor noted "significant parenchymal disease" which he found to be consistent with "mild asbestosis." Dr. R.B. also noted that a CT (computerized tomography) scan may be needed to better define if fibrosis was present. It does not appear that a CT scan was conducted by Dr. R.B in November 2000. Further, a March 2007 VA treatment record noted a "background of chronic interstitial lung disease." This evidence weighs in favor of establishing a current diagnosis for a respiratory disability; however, it is only a notation regarding a history of interstitial lung disease. The only diagnosis provided was from Dr. R.B. in the November 2000 report. The Board finds that a review of VA treatment records does not reveal a diagnosis for interstitial lung disease. As such, VA treatment notes of record weighs against a finding of a current diagnosis for a respiratory disability. Also weighing against the claim for service connection for a respiratory disorder is a December 2010 VA examination report. During the evaluation, the VA examiner noted that PFT results were normal and there was no finding of asbestosis on the day of the examination. There was also no evidence of cor pulmnale, pulmonary hypertension, or right ventricular hypertrophy. In reviewing the evidence, the VA examiner stated that the Veteran served in the U.S. Navy from 1948 to 1952 prior to working in a shipyard environment. The VA examiner indicated that the Veteran was exposed to "asbestosis" with no personal protective equipment while working as a boilermaker from 1955 to 1975. The VA examiner noted that the first medical evidence suggesting the presence of asbestosis was the November 2000 private treatment record from Dr. R.B. In the most recent January 2013 VA examination report, the Veteran denied any problems with cough or shortness of breath. He stated that he was nonsmoker, however, in a geriatric exam it was mentioned that the Veteran stopped smoking in 1963. He also reported asbestos exposure in the 1940s and stated that he was a boiler repairman in the Navy between 1947 and 1952 and then in Coast Guard from 1952 to 1967. Also, he reported that, after service, he again worked at a naval ship yard for five years until 1975. The examiner noted that the Veteran's past chest x-rays and PFTs mentioned no interstitial lung problem, and no pleural problem. Upon examination in January 2013, chest x-ray and PFT results were normal. In reviewing records from the claims file, the VA examiner discussed the report from Dr. R.B. in 2000 who diagnosed mild asbestosis; however, with a normal PFT at the 2000 evaluation, the examiner stated that there was no evidence to support the diagnosis of "mild asbestosis." The examiner opined that the Veteran did have asbestos exposure. The VA examiner reasoned that multiple chest x-rays and multiple PFT reports did not find lung parenchymal or pleural calcifications, including chest x-rays performed in January 2013. Therefore, the VA examiner opined that the Veteran was less likely than not having a respiratory disorder both current or in the past. The VA examiner found no evidence of cardiomegaly, pulmonary edema, or interstitial lung disease. The Board finds that the January 2013 VA medical opinion weighs against a finding of a current respiratory disability. Upon review of all the evidence of record, the Board finds that the Veteran does not have a current diagnosis of a respiratory disability, to include asbestosis. In reaching this conclusion, the Board finds the December 2010 and January 2013 VA examination reports and opinions to be of greater probative weight than the opinion from Dr. R.B. For example, Dr. R.B. did not provide a rationale as to how a diagnosis of mild asbestosis was rendered despite his findings that the Veteran's lungs were clear on auscultation, the PFT was normal, and a CT scan was not conducted in order to detect whether fibrosis was present. The Board notes that "asbestosis" is defined, in pertinent part, as "a form of pneumoconiosis (silicatosis) caused by inhaling fibers of asbestos, marked by interstitial fibrosis of the lung." See Dorland's Illustrated Medical Dictionary, 163-164 (32nd ed. 2012). Unlike Dr. R.B., the December 2010 and January 2013 VA examiners based their opinions on a more thorough history and findings, including review of the claims file, which documented normal chest x-rays, normal PFT reports, and numerous evaluations by VA medical professionals showing that the Veteran's lungs were clear on auscultation. The December 2010 and January 2013 VA examiners found that there was no evidence of a pulmonary disorder, to include asbestosis. Further, these opinions were provided 10 and 13 years after the opinion from Dr. R.B. in 2000. Given that fibers of asbestos remain in the lungs during the entire period of an individual's lifetime, it is unlikely that asbestosis would have been detected in 2000, but not in 2010 and 2013. Accordingly, the Board finds that the weight of the evidence of record demonstrates that the Veteran does not have a current respiratory disorder, to include asbestosis. In the absence of proof of a present disability there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). For these reasons, the Board finds that a preponderance of the evidence is against the claim for service connection for a respiratory disorder, to include as a result of in-service asbestos exposure, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection for Left Ankle Disorder In a September 2008 statement, the Veteran reported that, during service on a naval vessel in 1950, he sprained his left ankle and burned his left leg on an uninsulated steam line. He also stated that during service in 1957 he sprained his right ankle and was sent home for a brief period of time. Once at home, the Veteran claims that while getting up from a chair he stepped on his children's rocking chair, tripped, and injured his left ankle. See September 2008 statement and July 2010 Hearing Transcript, pages 21-22. In a September 1957 service treatment record, examiners indicated treating the Veteran for a right (not left) ankle sprain and left foot sprain. After six days of in-patient treatment, the Veteran was discharged for duty. Notably, service treatment records do not reveal any complaints, treatment, or diagnosis for a left ankle injury. The Board acknowledges that the foot and ankle are in close anatomical proximity to one another; however, the September 1957 in-service medical professional specifically distinguished the ankle sprain from the foot sprain. Ankle disorders and foot disorders are distinct disabilities that warrant separate ratings for VA disability compensation purposes. See 38 C.F.R. § 4.71a (2012). The Board finds that these sprains (i.e., to the foot versus the ankle) are separate and distinct injuries; therefore, despite a left foot sprain during service, the Board finds that the Veteran did not sustain an in-service injury to his left ankle. The Board further finds that the evidence of record demonstrates current diagnoses of a left ankle sprain and left plantar calcaneal spur. See November 2007 VA treatment note, December 2010 VA examination report, and January 2013 VA examination report. The Board next finds that the weight of the evidence of record demonstrates that the Veteran's left ankle disorder is not related to service, to include the left foot sprain in 1957. In this regard, service medical examination reports, dated from May 1959 through August 1966, indicate that the Veteran's lower extremities were normal upon examination. In a June 1967 service treatment record, indicating an examination upon discharge from service, the Veteran's extremities were noted to have no cyanosis, no edema, and good motor strength. This evidence weighs against a finding that the Veteran's left ankle disorder began in service, is otherwise related to service, and shows no left ankle injury, disease, or symptoms in service. Moreover, this evidence demonstrates that the in-service left foot injury in service resolved without residuals. Post-service treatment records reveal that the Veteran first sought treatment for left ankle pain decades after service in November 2000. The Board finds that this treatment came 33 years after service separation. The Board finds that this evidence, in the context of no residual symptoms or disorder shown in service or after service separation, also weighs against a finding that the Veteran's left ankle disorder is related to service. Also weighing against the Veteran's claim is a December 2010 VA medical examination report and opinion. The examiner conducted and reviewed x-ray results, reviewed the claims file, and conducted a physical examination of the Veteran's left ankle. The examiner diagnosed the Veteran with a left ankle strain and left foot spur and opined that these disorders were less likely than not related to service. In support of his opinion, the VA examiner reasoned that there was no symptomatology, imaging, or evaluation until 2007. The Board finds that this factual assumption is accurate, as it is consistent with the evidence of record, and is consistent with the Board's findings in this case. The Board further finds that this evidence weighs against a relationship or nexus of the current left ankle disorder to service. Weighing against the Veteran's claim for service connection is a January 2013 VA examination report and opinion. The January 2013 VA examiner reviewed the claims file, reviewed x-ray findings, and discussed the Veteran's medical history in detail. The VA examiner noted that a review of military medical records revealed a right ankle sprain on September 25, 1957 and September 26, 1957, which was treated with whirl pool and an ice pack. Upon review of x-ray reports, the VA examiner noted that it did not appear that the Veteran had degenerative joint disease at age 82. The VA examiner noted that the Veteran's complaints of not being able to move his left ankle and range of motion decreased when he extended his left knee. This, the examiner opined, did not support an ankle problem, but appeared to be more related to the back surgeries and currently diagnosed spinal stenosis. For these reasons, the examiner opined that the Veteran's left ankle disorder was less likely than not related to service. In support of this opinion, the examiner noted no continuous documentation of care and no difference in past and current examination of the left ankle. The Board finds the January 2013 VA medical opinion to be highly probative on the question of a nexus to service. The Board notes that the record does not contain any medical opinions demonstrating a relationship between the Veteran's currently diagnosed left ankle sprain or left plantar calcaneal spur to active service. The Board has considered the Veteran's statements regarding persistent symptoms of left ankle pain since service separation and his contention that his current disability is related to the in-service ankle injury. While the Veteran is competent to report symptoms as they come to him through his senses (ankle pain), the etiology of his left ankle disorder, which includes the consideration of such factors as residuals of an ankle sprain, affects of a left heel spur, residuals of back surgeries, and current spinal stenosis, is not the type of disorder that a lay person can provide competent evidence on questions of etiology. See Layno, 6 Vet. App. at 465 (competent lay evidence is evidence not requiring that the proponent have specialized education, training, or experience, but is provided by a person who has knowledge of facts or circumstances and conveys matter that can be observed and described by a lay person); see also Rucker, 10 Vet. App. at 74 (stating that a lay person is not competent to diagnose or make a competent nexus opinion about a disorder as complex as cancer). Here, the Board finds the December 2010 and January 2013 VA opinions to be the most probative and competent evidence of record as to the etiology of the Veteran's left ankle disorder. The examiners conducted x-rays, reviewed past x-ray reports, considered the Veteran's spinal condition, and reviewed the in-service and post-service medical history. The Board further finds that the Veteran's more recent assertions of left ankle pain since service separation are not credible. As discussed above, service treatment records, including the June 1967 service separation examination, are void of any complaints or treatment for a left ankle injury. Further, post-service treatment records reveal that the Veteran first sought treatment for left ankle pain 33 years after service separation. Moreover, the January 2013 VA medical opinion, which the Board has found to be highly probative, relates the Veteran's left ankle pain to post-service back surgeries and currently diagnosed spinal stenosis, and not to service. For these reasons, the Board finds that the Veteran's more recent statements of persistent symptoms of left ankle pain after service, made pursuant to the claim for VA compensation, are outweighed by other medical evidence of record. See Cartright, 2 Vet. App. at 25; Pond v. West, 12 Vet. App. 341 (1991) (interest may affect credibility of testimony). Based on the evidence of record, the weight of the competent evidence demonstrates no relationship between the Veteran's left ankle disorder and his military service. For these reasons, the Board finds that a preponderance of the evidence is against the claim for service connection for a left ankle disorder, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for a respiratory disorder, to include as a result of in-service asbestos exposure, is denied. Service connection for a left ankle disorder is denied. REMAND The issue of service connection for a heart disorder, to include as secondary to PTSD, was previously before the Board in June 2012, at which time it was remanded for a supplemental medical nexus opinion. As explained below, that development was not fully accomplished; therefore, the issue must be remanded for a supplemental medical opinion. See Stegall, 11 Vet. App. 268. In the June 2012 remand, the Board noted that the evidence of record revealed diagnoses of mild mitrial regurgitation, trace pulmonary regurgitation, and diastolic dysfunction diagnosed in October 2007. The VA examiner was asked to provide an opinion as to the most likely cause of the Veteran's diagnosed heart disorder. The January 2013 VA examiner suggested that the Veteran may have had a family history of heart disease (mother died of heart attack at age 77); however, an opinion as to the most likely cause of the Veteran's heart disorders was not provided. Further, the VA examiner did not discuss the heart disorders diagnosed in October 2007, including mild mitrial regurgitation, trace pulmonary regurgitation, and diastolic dysfunction. Further, the January 2013 VA examiner was asked to render an opinion as to whether it was at least as likely as not that the Veteran's diagnosed heart disorder(s) had their onset in service or were related to an incident of the Veteran's service. Although the January 2013 VA examiner opined that the Veteran's heart disorders were less likely than not related to service, a rationale or basis for the opinion was not provided. The VA examiner only stated that the Veteran's heart disorders first appeared in 1975, eight years after service separation. The examiner was also asked to provide an opinion as to whether it was at least as likely as not that the Veteran's diagnosed heart disorder(s) were caused or aggravated by his service-connected PTSD. Again, the examiner stated that the Veteran's heart disorders were less likely than not related to PTSD; however, a rationale or basis for the opinion was not provided. Instead, the examiner noted that the Veteran's heart disorder appeared in 1975 and he was found unfit for duty in 1967 due to anxiety and was later found to have PTSD. The Board finds that this rationale is inadequate as it does not provide an explanation as to whether the well-documented in-service symptoms of anxiety and later diagnosed PTSD caused and/or aggravated the Veteran's heart disorder(s). Once VA undertakes to provide an examination it is obligated to insure that the examination is adequate. Barr, 21 Vet. App. 303. An adequate medical opinion addresses the appropriate theories of entitlement and provides a supporting rationale for any medical opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 123-25 (2007). As this medical opinion is inadequate, a remand is required. Accordingly, the issue of service connection for a heart disorder, to include as secondary to PTSD, is REMANDED for the following action: 1. Obtain a supplemental opinion from the VA examiner who provided the January 2013 VA medical opinion. If that examiner is not available, obtain an opinion from another appropriate VA examiner. If the reviewer determines that examination of the Veteran is necessary to provide a reliable opinion, such examination should be scheduled. The relevant documents in the claims folder should be made available to and reviewed by the reviewer/examiner. Then, the examiner should provide the following opinions: (a) What are the Veteran's currently diagnosed heart disorder(s) (e.g., coronary artery disease, ventricular arrhythmia, mild mitrial regurgitation, trace pulmonary regurgitation, diastolic dysfunction)? (b) What is the most likely cause of each of the Veteran's currently diagnosed heart disorder(s)? (c) Is it at least as likely as not that the Veteran's diagnosed heart disorder(s) are related or caused by service? A rationale for the opinion(s) stated should be provided. (d) Is it at least as likely as not that the Veteran's diagnosed heart disorder(s) are caused by his service-connected PTSD? The examiner should specifically address the in-service symptoms of anxiety and provide a rationale for the opinions rendered. (e) Is it at least as likely as not that the Veteran's diagnosed heart disorder(s) are aggravated by his service-connected PTSD? The examiner should specifically address the in-service symptoms of anxiety and provide a rationale for the opinions rendered. Note: The term "aggravated" in the above context refers to a permanent worsening of the pre-existing or underlying condition, as contrasted to temporary or intermittent flare-ups of symptoms which resolve with return to the previous baseline level of disability. If the VA examiner finds that any heart disorder found during the examination was aggravated by the Veteran's PTSD, he/she should quantify the degree of aggravation, if possible. The VA examiner is advised that the term "as likely as not" does not mean within the realm of possibility. Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is medically sound to find in favor of causation as to find against causation. The reasons should be given for any opinion provided. If an opinion cannot be provided without resort to pure speculation, the VA examiner should explain why speculation would be required in this case (e.g., if the requested determination is beyond the scope of current medical knowledge, actual causation cannot be selected from multiple potential causes, etc). The VA examiner should identify the relevant testing or other information needed to provide the requested opinion. 2. Following the completion of the requested actions, the AMC/RO should then re-adjudicate the Veteran's claim for service connection for a heart disorder, to include as secondary to PTSD. If the benefit on appeal remains denied, the Veteran and the representative should be provided with a Supplemental Statement of the Case, and should be afforded an applicable opportunity to respond. Thereafter, the case should be returned to the Board. The Veteran is advised that failure to report for any scheduled examination may result in the denial of his claim. 38 C.F.R. § 3.655 (2012). The Veteran has the right to submit additional evidence and argument on the matter 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). ____________________________________________ J. Parker Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs