Citation Nr: 1449986 Decision Date: 11/12/14 Archive Date: 11/19/14 DOCKET NO. 11-01 738 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Whether new and material evidence has been received to reopen the claim for service connection for a low back disability. 2. Whether new and material evidence has been received to reopen the claim for service connection for a bilateral knee disabilities. 3. Entitlement to service connection for sinusitis. 4. Entitlement to service connection for hemorrhoids. 5. Entitlement to service connection for bilateral foot disabilities. 6. Entitlement to service connection for bilateral elbow disabilities. 7. Entitlement to service connection for bilateral ankle disabilities. 8. Entitlement to service connection for bilateral wrist disabilities. 9. Entitlement to service connection for a liver disability. REPRESENTATION Appellant represented by: Virginia A. Girard-Brady, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD R. Erdheim, Counsel INTRODUCTION The Veteran served on active duty from March 1973 to April 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) that denied the claims on appeal. In September 2014, the Veteran testified before the undersigned Veterans Law Judge. As an initial matter, the Board notes that the issues of entitlement to an increased rating for gastroesophageal reflux disease (GERD) and peptic ulcer disease, entitlement to service connection for posttraumatic stress disorder and postoperative residuals and for cholelithiasis, and a TDIU, are not currently on appeal. The Veteran did not file a timely Form 9 to any of these issues and they have not been certified to the Board. FINDINGS OF FACT 1. The claim for service connection for a low back disability was previously denied in a December 2007 Board decision. The Veteran did not appeal the decision and it is therefore final. 2. Evidence added to the record since the last final December 2007 denial is cumulative and redundant of the evidence of record at the time of such decision and does not raise a reasonable possibility of substantiating the Veteran's claim for service connection for a low back disability. 3. The claim for service connection for a bilateral knee disability was previously denied in a December 2007 Board decision. The Veteran did not appeal the decision and it therefore final. 4. Evidence added to the record since the last final December 2007 denial is cumulative and redundant of the evidence of record at the time of such decision and does not raise a reasonable possibility of substantiating the Veteran's claim for service connection for a bilateral knee disability. 5. The weight of the probative evidence reflects that the Veteran's hemorrhoids were not present during service and are not due to any incident of his active duty service. 6. The weight of the probative evidence reflects that the Veteran's claimed sinusitis, diagnosed as allergic rhinitis, was not present during service and is not due to any incident of his active duty service. 7. The weight of the probative evidence reflects that the Veteran's liver disability, diagnosed a fatty liver disease, was not present during service and is not due to any incident of his active duty service. 8. The weight of the probative evidence reflects that the Veteran's bilateral foot disability, diagnosed as bunions, was not present during service and is not due to any incident of his active duty service. 9. The Veteran does not have a current diagnosis of a bilateral elbow disability. 10. The Veteran does not have a current diagnosis of a bilateral ankle disability. 11. The Veteran does not have a current diagnosis of a bilateral wrist disability. CONCLUSIONS OF LAW 1. The December 2007 Board decision that denied service connection for a low back disability is final. 38 U.S.C.A. § 7104(b) (West 2002); 38. C.F.R. § 20.1100, (2014). 2. New and material evidence has not been received to reopen the claim of entitlement to service connection for a low back disability. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2014). 3. The December 2007 Board decision that denied service connection for bilateral knee disability is final. 38 U.S.C.A. § 7104(b) (West 2002); 38. C.F.R. § 20.1100, (2013). 4. New and material evidence has not been received to reopen the claim of entitlement to service connection for a bilateral knee disability. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2014). 5. The Veteran's hemorrhoid disability was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2014). 6. The Veteran's claimed sinusitis was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2014). 7. The Veteran's liver disability was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2014). 8. The Veteran's bilateral foot disability was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2014). 9. Contended bilateral elbow disability was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2014). 10. Contended bilateral ankle disability was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2014). 11. Contended bilateral wrist disability was not incurred or aggravated in service. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2014). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100 , 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). With respect to claims to reopen, VA must both notify a claimant of the evidence and information that is necessary to reopen the claim and notify the claimant of the evidence and information that is necessary to establish entitlement to the underlying claim for the benefit that is being sought. Kent v. Nicholson, 20 Vet. App. 1 (2006). Notice for the Veteran's claim, including Kent notice, was provided in a letter dated in June 2008 and October 2008. In February 2009, following such notice, a rating decision was issued that denied the claims on appeal. With regard to the duty to assist, the claims file contains the Veteran's service treatment records, VA and private medical records, and statements by the Veteran. Proper procedure was followed with respect to requesting and obtaining private medical records. The Board has carefully reviewed the record and concludes that there has been no identification of further available evidence not already of record. An adequate VA examination and opinion was obtained with respect to the claim for service connection for sinusitis in October 2010, with respect to the claim for a liver disorder in January 2009, and with respect to the claim for hemorrhoids in September 2008. With regard to the claims for service connection for bilateral elbow disabilities, bilateral ankle disabilities, and bilateral wrist disabilities, because there is no evidence that the Veteran has a current diagnosis of these disabilities, the Board finds that a remand for VA examination is not necessary to decide the claims. And, although there is a current diagnosis of a bilateral foot disability, that of bunions, the competent and credible evidence of record fails to indicate that the Veteran may have incurred such disability in service or that bunions are otherwise related to the Veteran's service. Moreover, the Veteran has offered only conclusory statements regarding service incurrence of these claimed disabilities. A mere conclusory generalized lay statement that a service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed.Cir. 2010). As explained below, the Board finds no indication that bilateral foot disabilities, bilateral elbow disabilities, bilateral ankle disabilities, and bilateral wrist disabilities, or persistent or recurrent symptoms of such disorders, may be associated with the Veteran's military service. Thus, a remand for examination and/or opinion is not necessary to decide the claim. See 38 C.F.R. § 3.159 (c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006) (discussing circumstances when a VA examination is required). Finally, a VA examination or opinion has not been obtained with regard to the claims to reopen the previously denied claims for service connection for a low back disability and a bilateral knee disability. However, because the Board finds that new and material evidence has not been submitted, the duty to assist to obtain a medical examination has not been triggered. The Veteran was also provided with a hearing related to his present claims. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires the Veterans Law Judge (VLJ) who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, the VLJ explained the issues on appeal, and made note of the specific elements necessary to substantiate the service connection claims and claims to reopen. The VLJ also suggested the submission of any additional evidence. Accordingly, the Veteran is not shown to be prejudiced on this basis. The Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor has he identified any prejudice in the conduct of the Board hearing. As such, the Board finds that, consistent with Bryant, the hearing complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to his claims. Thus, the VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claims at this time. II. Analysis New & Material Evidence In October 2006, the RO denied the Veteran's claim of entitlement to service connection for a low back disability and bilateral knee disabilities. In December 2007, the Board also denied these claims. The Veteran did not appeal the Board decision and it is therefore final. 38 U.S.C.A. §§ 7103; 38 C.F.R. § 20.1100. Although the RO determined in a February 2009 rating decision that new and material evidence sufficient to reopen the claim for a low back disability and bilateral knee disabilities had not been submitted, the Board must consider the question of whether new and material evidence has been received because it goes to the Board's jurisdiction to reach the underlying claim and adjudicate the claim de novo. Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). If the Board finds that no such evidence has been offered, that is where the analysis must end, and what the RO may have determined in that regard is irrelevant. Id. By way of history, in an October 2006 rating decision, the claim for service connection for a low back disability and a bilateral knee disability was denied. The RO stated that there was no indication of a back or knee disability in service and there was no current diagnosis of a back or knee disability. The Veteran appealed that decision. In December 2007, the Board denied the claims, finding that although the Veteran had a current diagnosis of a lumbar spine disability, there was no indication that the disability was caused or aggravated by his service. The evidence did not show the presence of a current disability of either the right or left knee. A claim of entitlement to service connection may be reopened if new and material evidence is submitted. Manio v. Derwinski, 1 Vet. App. 140 (1991). The Veteran filed this application to reopen his claim in October 2008. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with the 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). In determining whether evidence is new and material, the credibility of the new evidence is presumed. Justus v. Principi, 3 Vet. App. 510 (1992). The evidence before VA at the time of the prior final decision consisted of the Veteran's service treatment records, VA and private treatment records, and the Veteran's own statements, as described above. Those records showed a diagnosis of a low back disability, but no diagnosis of a bilateral knee disability, including on x-ray examination. The records also did not show an indication of a back or right or left knee disability in the service treatment records or for many years following service separation. In support of his application to reopen the claim, the Veteran contended that when he was in service, he fell out of a truck and injured his back and his knees. He contended that he was treated in service for these injuries. However, these contentions were previously known and were taken into consideration at the time of the December 2007 Board denial. Thus, these new statements do not substantiate any of the missing elements of service connection, namely evidence of symptoms in service, continuity since service, or a medical nexus relating the symptoms to service. The Veteran's statements are mainly cumulative of those considered at the time of the last final decision on this issue. The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is "low." Moreover, in determining whether this low threshold is met, consideration need not be limited to consideration of whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, either by triggering the VA's duty to assist or through consideration of an alternative theory of entitlement. See Shade v. Shinseki, 24 Vet. App. 110 (2010). Unlike Shade, the Board has not failed to properly apply 38 C.F.R. § 3.156(a) to the evidence presented in the current claim to reopen. Here, as noted in detail above, the new evidence of record was not found to be material as it did not relate to an unestablished fact necessary to substantiate the claims. Evidence previously of record failed to demonstrate symptoms of a low back disability or bilateral knee disability in service, any indication of continuity of symptoms following service separation, or a medical nexus relating a current disability to service. When considering newly submitted evidence in conjunction with the evidence previously of record, the Board has not required the Veteran to submit evidence as to each previously unproven element of his claim. In this case, the Board finds that evidence supporting the Veteran's claim is insufficient to trigger the duty to assist. Therefore, although the Veteran has submitted new evidence that was not before the VA in December 2007, the new evidence is not material to the claim and does not warrant reopening of the previously denied claim. In light of the evidence, it is the determination of the Board that new and material evidence has not been submitted. Thus, the claims for service connection for a low back disability and bilateral knee disabilities are not reopened and the benefits sought on appeal remain denied. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may be granted with medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307, (ii) present manifestations of the same chronic disease, and (iii) evidence of continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran's claimed sinusitis, hemorrhoids, and liver disability are not contemplated by this regulation. Cirrhosis of the liver has not been diagnosed. Therefore credible lay evidence of continuous symptoms can support the claim. Claimed arthritis is contemplated by this regulation. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including claimed arthritis, to a degree of 10 percent within one year from the date of termination of such service such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. 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(a) (2014). The Board also notes that secondary service connection on the basis of aggravation is permitted under 38 C.F.R. § 3.310, and compensation is payable for that degree of aggravation of a nonservice- connected disability caused by a service-connected disability. See 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). Sinusitis, Hemorrhoids, Liver Disability, & Bilateral Foot Disabilities With regard to the Veteran's claim for service connection for sinusitis, the Veteran contends that he was treated for sinusitis while serving in Italy. The Veteran's service treatment records reflect that he suffered from numerous upper respiratory illnesses throughout his service. For example, in April 1973, the Veteran had a cold with a runny nose. He was given a cold pack. In October 1973, he complained of a chest cold and coughing, with some phlegm. The diagnosis was an upper respiratory infection. He was prescribed Dimetapp. In January 1974, he was coughing, with symptoms of rhinorrhea for three days. He was again given Dimetapp. In January 1978, he was treated for the flu, with symptoms of sinus drainage and slight congestion. In September 1978, he had a sinus cold, congestion, and a sore throat for two days. He was diagnosed with an upper respiratory infection. Post-service treatment records reflect that in March 1979, VA examination showed normal sinus examination. In March 1979, the Veteran underwent a tuberculosis examination because of a previous positive test. He reported daily coughing but no other symptoms such as sinus drainage or congestion. A November 1992 chest x-ray on VA examination was negative. VA treatment records reflect that in 2003, the Veteran had an ongoing diagnosis of "probably allergic rhinitis." He had an itchy throat, dry cough, sneezing, and runny nose for one month. More recent VA treatment records reflect a diagnosis of chronic obstructive pulmonary disease that was considered to be related to a thirty year smoking history and to asbestos exposure. On October 2010 VA examination, the Veteran reported breathing difficulty and post nasal drip. He treated the symptoms with nasal spray and antihistamines. He reported having nasal blockage. Following physical examination of the Veteran, the examiner diagnosed him with allergic rhinitis. The examiner explained that the Veteran's symptoms and treatment were for rhinitis, rather than sinusitis. His symptoms were primarily seasonal and treated with allergy medications. The examiner concluded that it was less likely than not that the Veteran's allergic rhinitis was caused or aggravated by his service. A review of the service records showed that the Veteran was treated for congestion and upper respiratory illness which was usually related to viral infections, rather than to sinus infections. The Veteran also had a history of tobacco abuse which would predispose him to sinus and upper airway problems, as well as lung problems. Based on a review of the records and upon clinical expertise, his current rhinitis was not related to his complaints during active military service. In this case, the Board finds that the weight of the credible and competent evidence of record is against the Veteran's claim for service connection for sinusitis. Although the Veteran's service treatment records reflect that he suffered from various upper respiratory illnesses in service, those records were reviewed and taken into account by the 2010 VA examiner when providing the negative opinion. The examiner concluded that the Veteran's in-service illnesses were viral in nature, rather than indicative of or related to the Veteran's current disability which presented as seasonal allergic rhinitis. Therefore, the examiner found no relationship between the current disability and the Veteran's in-service symptoms and treatment. In that regard, the Board finds that the elements of service connection have not been met. There is no indication of a chronic upper respiratory disability, including allergic rhinitis or sinusitis, in service. As clarified by the VA examiner, the service records showed acute viral infections. Service separation examination was negative for any upper respiratory disability. Next, although the Veteran has testified that his upper respiratory symptoms have worsened since service, the evidence does not support a finding of continuity of symptoms since service. Rather, a 1979 VA examination was negative for any findings or diagnosis of sinusitis or allergic rhinitis. When the Veteran was examiner for tuberculosis, no upper respiratory illness was diagnosed. The first indication of treatment for or a diagnosis of allergic rhinitis was not until many decades following service separation. And, as explained by the 2010 VA examiner, the Veteran's current symptoms diagnosed during the appeal period are not indicative of a chronic disability that was caused or aggravated by his service. There is no medical evidence of record to support the Veteran's claim. Moreover, the Veteran's statements of service incurrence and continuity since service have been vague and conclusory in nature. Thus, after review and analysis of the evidence, the Board finds that service connection for sinusitis must be denied. With regard to his claim for service connection for hemorrhoids, at his 2014 hearing before the Board, the Veteran stated that he first suffered from constipation and hard stools leading to hemorrhoids when he was stationed in Fort Hood, Texas, in 1982. At his June 2010 hearing before a Decision Review Officer, the Veteran stated that he was first treated for his hemorrhoids in service in about 1978. In other documents of record, the Veteran stated that he was first treated for hemorrhoids while stationed in Italy. Post-service treatment records reflect that the Veteran carried a diagnosis of hemorrhoids in 2007, when he was hospitalized for bright red blood from the rectum. In December 2007, colon and upper endoscopy were normal except for hemorrhoids, which were deemed the source of the blood. VA treatment records dated in 2006 are negative for a diagnosis of hemorrhoids. On September 2008 VA examination, the VA examiner reviewed the Veteran's service treatment records and post-service treatment records and determined that the Veteran's hemorrhoids were not related to his service. In this case, the Board finds that the weight of the credible and competent evidence of record is against the Veteran's claim for service connection for hemorrhoids. For one reason, the Board notes that the service treatment records are negative for any symptoms or treatment for hemorrhoids. While the Veteran reported that he suffered from constipation and hard stools in service, and was treated for hemorrhoids in service, the Board finds his testimony to be of low probative value. For, although the Veteran is competent to report these symptoms, his testimony has varied widely during the appeal period, in that his report of onset has ranged from 1974 to 1982. Also, his report as to the circumstances of his symptoms has varied, in that he first stated that his hemorrhoids were treated in Italy, but then stated that his symptoms of constipation and hard stools were treated at Fort Hood. In light of the fact that his service records are negative for any such treatment, and the Veteran's report of service incurrence has been inconsistent, and therefore lacking in credibility, the Board finds that the medical records outweigh the Veteran's statements. Next, the Board finds that there lacks any indication of continuity of symptoms in this case, as the first indication of hemorrhoid symptoms or treatment is not until many decades following service separation. Finally, the medical opinion of record found that the Veteran's hemorrhoids were not related to his service. Such opinion was based upon a review of the service records and post-service records, and was provided based upon medical expertise and knowledge. The Board accords the opinion greater probative value than the Veteran's lay statements for the reasons stated above, to include that the nature of the Veteran's testimony has been vague and conclusory. Accordingly, because the elements of service connection have not been met, service connection for hemorrhoids must be denied. With regard to the Veteran's claim for service connection for a liver disability, the Veteran contends that his liver disability first manifested either in service or shortly following separation from service. Alternatively, he contend that his liver disability was caused or aggravated by his service-connected GERD. Service treatment records are negative for any disease or disability related to the liver. Post-service treatment records reflect a current diagnosis of fatty liver disease. An August 2007 liver function test showed elevated levels. Prior to that time, the Veteran had reported a chronic left-sided abdominal lump that he had had for 25 years. A 2003 abdominal ultrasound had shown fatty infiltration of the liver. On September 2008 VA examination, after reviewing the claims file and physically examining the Veteran, the examiner concluded that the Veteran's liver disability was due to a long history of ethanol abuse and the more recent onset of diabetes mellitus. Neither of those condition were noted in service, and the Veteran's liver disability was not due directly to any condition or incident of service. On January 2009 VA examination, it was noted that the Veteran had a long history of alcohol abuse from 1976 until 2006. Physical examination of the Veteran and review of the claims file resulted in a conclusion that the Veteran's fatty liver disease was not caused or aggravated by the Veteran's service-connected GERD. The examiner explained that the case was discussed with the station Hepatologist who confirmed that there was no known association between fatty liver disease and GERD or peptic ulcer disease. In this case, the Board finds that the weight of the credible and competent evidence of record reflects that the Veteran's liver disorder was not caused or aggravated by his service or by his service-connected GERD. On a direct basis, the Board finds that there is no indication of a liver disability in service. Notably, none was reported or found on separation examination. There is also no indication of continuity of symptoms since service, as the first indication of fatty liver disease was not until many decades following service separation. In that regard, the Veteran has not provided any details as to the onset of his liver disease, stating only that he began treatment for such within a few years of service separation. However, the post-service medical records reflect that it was not until the 2000s that the Veteran underwent a liver function test and ultrasound showing the presence of his liver disease. Moreover, the 2008 VA examiner concluded that the Veteran's fatty liver disease was due to his many years of alcohol abuse and due to his diabetes, a nonservice-connected disability. There was no indication that the Veteran's liver disability was caused or aggravated by his service. The evidence also does not support the Veteran's claim on a secondary basis, as the 2009 VA examiner, after discussing the case with a medical specialist, concluded that there was no known relationship between the Veteran's fatty liver disease and his GERD and peptic ulcer disease. Thus, it was less likely than not that the Veteran's service-connected GERD and/or peptic ulcer disease caused or aggravated his liver disability. With respect to aggravation, because there was no relationship between the two disabilities from a clinical standpoint, the Board finds it reasonable to conclude that there would be no causal relationship or relationship based upon aggravation, as the two conditions bore no relationship. Accordingly, because the elements of service connection have not been met on a direct or secondary basis, service connection for a liver disability must be denied. With respect to the Veteran's claim for service connection for bilateral foot disabilities, the Veteran contends that while in service, he developed bunions and was treated for such due to wearing his boots for long periods of time each day. He also claimed at his hearing before the Board that he suffered from bursitis of the feet and flatfeet. The service treatment records are negative for a diagnosis of bunions, bursitis, or flatfeet. One entry in September 1977 states that the Veteran had pain in his feet bilaterally for two weeks. The pain was mostly in the heels and started at the ball of the feet. There were circumscribed ulcerations on the heels and at the beginning of the balls of the feet and toes. The diagnosis was ?dyshydrosis. Post-service treatment records reflect that in September 2007, the Veteran reported pain in the great toe of both feet. X-ray showed a valgus deformity at the head of the metatarsal joint. The Veteran reported no trauma or injury. Thorough physical examination resulted in the diagnosis of hallux valgus, both feet. In this case, the Board finds that the weight of the credible and competent evidence of record is against the Veteran's claim for service connection for bilateral foot disabilities. Although the Veteran's service treatment records reflect that he was treated for foot pain on one occasion, the assessment in that instance was of a dermatological pathology, that of a blister condition, rather than to the bony pathology of bunions. Moreover, the part of the foot affected was not the same as when he was diagnosed with bunions in 2007. Thus, it is clear that the in-service diagnosis was for a condition of the skin, rather than of the foot itself. It is significant that the remainder of the service records are negative for complaints related to the feet. In that regard, the Board finds that the elements of service connection have not been met. There is no indication of bunions, or any other foot disability, in service. Next, the evidence does not support a finding of continuity of symptoms since service. The Veteran has vaguely stated that he had foot pain and swelling in service and since service, however, he has also stated that he has been diagnosed with flatfeet and bursitis, but the post-service medical evidence do not support such findings. In that regard, the Board finds that the medical evidence outweighs the Veteran's contentions, as the Veteran has been inconsistent and unclear as to the etiology and diagnoses of his foot disabilities. There is additionally no medical evidence to support the Veteran's claim. Thus, after review and analysis of the evidence, the Board finds that service connection for a bilateral foot disability must be denied. Bilateral Elbow, Wrist, and Ankle Disabilities With regard to the Veteran's claims for service connection for a bilateral elbow disability, bilateral wrist disability, and bilateral ankle disability, the Board finds that the first element of service connection, that of a current disability, has not been met at any time during the appeal period, and thus the claims cannot prevail. VA treatment records reflect that x-ray of the knees has been negative for abnormality, including arthritis. Moreover, although the Veteran has complained of joint pain and has been noted to suffer from arthralgia, a disability of the wrists, ankles, and elbows and has not been diagnosed. Pain alone, without a diagnosed or identifiable underlying malady or condition, does not constitute a disability for which service connection may be granted. Sanchez-Benitez v. West, 13 Vet. App. 282 (1999). Accordingly, service connection for a disability of the wrists, ankles, and elbows must be denied. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Caluza v. Brown, 7 Vet. App. 498, 505 (1995) (recognizing that "[a] service connection claim must be accompanied by evidence which establishes that the claimant currently has the claimed disability"). Lay Statements The Veteran has contended on his own behalf that he suffers from sinusitis, hemorrhoids, a liver disability, and bilateral foot, ankle, wrist, and elbow disabilities that are related to his military service, and that his liver disability was caused or aggravated by his service-connected GERD. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), the specific issues in this case 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)." Because, while the Veteran is competent to describe certain symptoms, such as pain in the rectum, congestion of the nose, and pain of the joints, the Board accords his statements regarding the etiology of such disorders less probative value as he is not competent to opine on such complex medical questions. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). Moreover, as explained in further detail above, the Veteran has only offered conclusory statements regarding the relationship between his sinusitis, hemorrhoids, a liver disability, and bilateral foot, ankle, wrist, and elbow disabilities and his military service, and his liver disability and his service-connected GERD. By contrast, the medical evidence does not support his claims and, multiple VA examiners took into consideration all the relevant facts in providing their opinions, as described in detail above. Therefore, based on the competent and probative evidence of record, the Board finds that service connection is not warranted for the issues on appeal. As the preponderance of the evidence is against the Veteran's claims, the claims must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER New and material evidence having not been received, the claim to reopen the previously denied claim for service connection for a low back disability is denied. New and material evidence having not been received, the claim to reopen the previously denied claim for service connection for bilateral knee disabilities is denied. Service connection for sinusitis is denied. Service connection for hemorrhoids denied. Service connection for bilateral feet disabilities is denied. Service connection for bilateral elbow disabilities is denied. Service connection for bilateral ankle disabilities is denied. Service connection for bilateral wrist disabilities is denied. Service connection for a liver disability is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs