Citation Nr: 1544197 Decision Date: 10/15/15 Archive Date: 10/21/15 DOCKET NO. 11-19 268 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Paul, Minnesota THE ISSUES 1. Entitlement to service connection for right knee degenerative joint disease with total knee arthroplasty. 2. Entitlement to service connection for left knee degenerative joint disease with total knee arthroplasty. 3. Entitlement to service connection for upper back disability. 4. Entitlement to service connection for bilateral hand condition. 5. Entitlement to service connection for left thumb metacarpal joint arthrosis. 6. Entitlement to service connection for chronic headaches. 7. Entitlement to service connection for bilateral pes planus with bilateral first metatarsophalangeal joint degenerative joint disease and bunionectomies. 8. Entitlement to service connection for right foot claw toe deformities. 9. Entitlement to service connection for right gastrocnemius contracture. 10. Entitlement to an initial rating in excess of 10 percent for bilateral tendinitis, carpal tunnel syndrome, and ulnar nerve entrapment. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Amanda Christensen, Associate Counsel INTRODUCTION The Veteran had active military service from November 1990 to May 1991. This appeal initially came before the Board of Veterans' Appeals (Board) from January 2011, July 2011, November 2011, and November 2012 decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. In September 2014, the Board denied the Veteran's claim as to the above listed issues. The Veteran appealed this decision to the Court of Appeals for Veterans Claims (Court). In March 2015, the Court vacated the Board decision and remanded the Veteran's claim for action consistent with the directives of a joint motion for remand (JMR). The issues of entitlement to service connection for bilateral pes planus with bilateral first metatarsophalangeal joint degenerative joint disease and bunionectomies, right foot claw toe deformities, and right gastrocnemius contracture being remanded are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. The Veteran's right and left degenerative joint disease with total knee arthroplasty did not have its onset in service or within one year of service discharge, and is not shown to be etiologically related to service. 2. The Veteran's degenerative joint and disc disease of her cervical spine did not have its onset in service or within one year of service discharge, and is not shown to be etiologically related to service. 3. The Veteran's left thumb metacarpal joint arthrosis and bilateral hand arthritis did not have its onset in service or within one year of service discharge, and is not shown to be etiologically related to service. 4. The Veteran's chronic headaches are not an undiagnosed illness, did not onset in service, and are not etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for right knee degenerative joint disease with total knee arthroplasty have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309 (2013). 2. The criteria for service connection for left knee degenerative joint disease with total knee arthroplasty have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309 (2013). 3. The criteria for service connection for upper back disability have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309 (2013). 4. The criteria for service connection for left thumb metacarpal joint arthrosis have not been met. 38 U.S.C.A. §§ 1110, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.304, 3.307, 3.309 (2013). 5. The criteria for service connection for bilateral hand 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, 3.307, 3.309 (2013). 6. The criteria for service connection for chronic 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, 3.307, 3.309 (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). Additionally, service connection may be granted, on a secondary basis, for a disability which is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310 (2013). 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, 492 F.3d 1372. Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). In this case, the Veteran has been diagnosed with arthritis in her knees, back and hands, and arthritis is listed as a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker, 708 F.3d 1331. Service connection may also be established with certain chronic diseases, including arthritis, based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Because the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War, service connection may also be established under 38 C.F.R. § 3.317. See Robinson v. Peake, 21 Vet. App. 545, 553 (2008), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed. Cir. 2009); see also Schroeder v. West, 212 F.3d 1265, 1271 (Fed. Cir. 2000). Under that section, service connection may be warranted for a Persian Gulf Veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi symptom illness, the disability must have been manifest either during active military service in the Southwest Asia Theater of operations or to a degree of 10 percent or more not later than December 31, 2016. See 76 Fed. Reg. 81, 834 (Dec. 29, 2011) (extending the delimiting date). For purposes of 38 C.F.R. § 3.317 a qualifying chronic disability is either: (1) an undiagnosed illness or (2) a medically unexplained chronic multi symptom illness that is defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders. An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C.A. § 1117; 38 C.F.R. § 3.317, unlike those for "direct service connection," there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Guiterrez v. Principi, 19 Vet. App. at 8-9. Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). 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). Knees The Veteran testified at her July 2014 Board hearing that she first began having problems with her knees in service as a result of helping build a tent hospital and digging sandbags during her active service deployment. She reported she worked long hours over a period of weeks. Her account of her physical activities is supported by statements by two fellow service members who served with her. In an August 2010 letter a medical officer who served with the Veteran recounted that the Veteran assisted in erecting, dismantling, moving, and re-erecting the evacuation hospital where they were stationed. He reported that she filled numerous sandbags over a period of weeks, kneeling to dig and fill the sandbags. He noted they did not use knee protection. The medical officer stated that that Veteran complained of general muscle and joint pain, including pain over her knees, and he gave her Motrin to relieve her pain. The Board acknowledges that the RO has issued a formal finding of the unavailability of the Veteran's service treatment records for the period from November 1990 to May 1992. Thus, the Board does not consider the lack of documentation of knee complaints on official medical records to weigh against the Veteran's claim. In fact, the Board finds the Veteran's reports of knee pain in service to be competent and credible and supported by the statement submitted by the medical officer who served with her, and by the statement submitted by her daughter, who recalled her mother complaining of knee pain while deployed. However, the Board notes that some service medical records from after the Veteran's deployment are of record. Specifically, the report of medical history forms completed by the Veteran herself in 1991 and 1997 are of record as well as service examinations conducted at the same time. Notably, on her April 1991 report of medical history the Veteran denied having a "trick" or locked knee or lameness. Further, her lower extremities were found normal on examination at that time. In addition, in February 1997 she again denied having a "trick" or locked knee or lameness and her lower extremities were again found normal on examination. Particularly notable is that the Veteran reported a number of other conditions on her report of medical history that did not involve her knees. Thus, the form does not indicate that the Veteran simply denied all problems, but rather that she indicated specifically which problems she was having at the time, which did not include her knees. In a January 2011 statement the Veteran's daughter stated that she recalled her mother complaining of knee pain while she was deployed. She also noted her mother quit running when she returned from service, stating that it was too painful. She also cited a trip in which she went sightseeing with her mother in 2001 and how her mother would indicate pain in her knees after walking. Private treatment records indicate that the Veteran sought treatment for bilateral knee pain in late 2005. She had a left total knee replacement in October 2006. In August 2009 she had a right total knee replacement. On her November 2010 VA examination the examiner diagnosed degenerative joint disease of both knees. In an August 2011 letter Dr. C. opined that with her plano valgus feet the Veteran had alignment issues throughout the extremity, which "might have played a role in increase[d] stress in her knees resulting in her knee replacements bilaterally." The Board finds this is opinion is too speculative to be of much probative value. See Stegman v. Derwinski, 3 Vet. App. 228, 230 (1992). See also, Tirpak v. Derwinski, 2 Vet. App. 609 (1992) (indicating that a doctor's opinion was too speculative when stating a disability "may be" related to service because this also was tantamount to saying the disability "may not be" related to service) and Bostain v. West, 11 Vet. App. 124, 127-28 (1998) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish medical nexus). See also, Perman v. Brown, 5 Vet. App. 227, 241 (1993) and Winsett v. West, 11 Vet. App. 420, 424 (1998). In an August 2010 statement, one of the Veteran's private physicians, Dr. A., opined that the Veteran's knee conditions were caused or permanently aggravated by her strenuous activities while in service, including digging and filling sandbags. He noted kneeling on her knees caused sufficient pain that she was given prescription strength Motrin. In September 2011, he further explained that he believed that due to the Veteran's activities in service she developed deterioration over the years in her knees and upper spine leading to the need for surgery. The Veteran was afforded a VA examination in November 2010. The report notes that the Veteran reported knee pain in service, then no problems for some time before the pain began again about ten years ago. She then had a left knee replacement in 2006 and a right knee replacement in 2009. The examiner opined that it is not at least as likely as not that her knee condition is related to the Veteran's service. The examiner explained that the Veteran's knee soreness in service was transient, she reported no trauma, and her knee pain resolved following her return to the United States. The examiner further noted that the chronic, degenerative changes experienced by the Veteran are commonly seen with aging. The Board finds that the medical evidence supports the opinion of the VA examiner that her knee pain in service was temporary and resolved prior to her release from active service. The Veteran denied knee trouble on medical history reports in both 1991 and 1997, and her lower extremities were found normal on examination both times. The Board particularly notes that the Veteran reported a number of other medical conditions in both 1991 and 1997, suggesting that if she had been experiencing continued knee pain at either time, she would have reported it along with her other conditions. The Veteran had clearly developed knee problems by 2005; however, that was more than a decade after her active service ended. The Board acknowledges the statement by the Veteran and her daughter that she had knee pain after service. However, the Board finds that the Veteran's own denials of knee pain in 1991 and 1997 weigh against the credibility of the current statements, made in connection with her claim for compensation. The Board finds the opinion of the VA examiner, who reviewed the Veteran's entire file, and addressed the more than a decade gap between the Veteran's service and her seeking treatment for knee pain, is the most probative opinion of record. The Board has considered the opinion of Dr. A. that her work on her knees in service caused deterioration over the years after service, but finds that his opinion is less probative as he offered no explanation for the large period of time when the record contains no complaints of knee pain and in fact, the Veteran denied knee problems. The Board acknowledges the Veteran's personal belief that her current knee problems are due to her service. The Board further acknowledges the Veteran's training and experience as a nurse and her reports that she worked on cases that included orthopedic matters and has taken classes on human anatomy and physiology. The Board also notes that the Veteran has described her nursing experience since service as one year of employment as a circulating nurse in an operating room, several years of unemployment, and then part-time employment as a circulating nurse in a day surgery center. As the Veteran certainly has some medical training, the Board does not doubt her competence to opine on some medical issues. However, the Board notes that the etiology of her knee problems is a complicated medical question, particularly considering the Veteran's age and length of time between the Veteran's service and her degenerative joint disease and ultimate knee replacement surgeries. The Board also notes that degenerative joint disease is a condition involving seen and unseen system processes that is diagnosed based on specialized imaging, not merely physical observation. The Board finds that the medical doctors who have offered opinions in this case have greater qualifications to opine as to such a complex etiology question. The Board further notes that the Veteran has offered little rationale to support her opinion, beyond arguing that she first had knee pain in service and had not since engaged in such strenuous activity as she had in service. Further, to the extent that her opinion is based on having had knee pain continuously since service, the Board has found that such contention is not credible. Therefore, the Board finds the Veteran's own etiology opinion has little probative value. Based on the forgoing, the Board finds that a preponderance of the evidence is against service connection for a bilateral degenerative joint disease of the knees. The Board has fully considered the Veteran's competent and credible assertions of pain in service. However, to the extent that the Veteran would now have the Board believe that her knee pain has continued unabated since service, the Board finds that the more contemporaneous evidence suggests her symptoms resolved. Therefore, although degenerative joint disease is a chronic disease, the Board finds that service connection is not warranted on a presumptive basis as it did not manifest to a compensable degree within one year following her separation from service. See 38 C.F.R. §§ 3.307, 3.309 (2013). Further, the condition was not shown to have existed in service nor does the evidence show a continuity of symptomatology since service. See 38 C.F.R. § 3.303(b); Walker, 708 F.3d 1331. The provisions pertaining to a Gulf War undiagnosed illness also do not apply as the Veteran's knee problems have been diagnosed as degenerative joint disease and are not due to an undiagnosed illness. Therefore, the Board finds that a preponderance of the evidence is against service connection for right and left knee disabilities, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. Spine The Veteran contends she has an upper spine condition related to her active duty service. The Veteran's service treatment records include no complaints of back or neck pain. However, a medical officer who served with her stated that the Veteran complained of upper back pain among other pains in service, for which he gave her Motrin. The Board acknowledges that the RO has issued a formal finding of the unavailability of the Veteran's service treatment records for the period from November 1990 to May 1992. Thus, the Board does not consider the lack of documentation of cervical spine complaints on official medical records to weigh against the Veteran's claim. In fact, the Board finds the Veteran's reports of back pain in service to be competent and credible and supported by the statement of the medical officer who served with her. However, the Board notes that some medical records from after the Veteran's deployment are available, specifically reports of medical history and service examinations from 1991 and 1997. On her April 1991 report of medical history the Veteran denied recurrent back pain. Further, her spine was found normal on examination. She again denied back pain in February 1997 on her medical history report and her spine was found normal on examination. Particularly notable is that the Veteran reported a number of other conditions on the reports of medical history, suggesting that she in fact did not have upper back problems at those times and she did not mark having any such complaints although she reported other conditions. A July 2002 MRI indicated the Veteran had moderate diffuse cervical spondylosis and bilateral facet arthropathy at C3-4 and C4-5 as well as advanced facet arthropathy on the left at C2-3. In January 2007 she had a complete anterior cervical discectomy and anterior spinal fusion. In an August 2010 statement, one of the Veteran's private physicians, Dr. A., opined that the Veteran's degenerative cervical spine was caused or permanently aggravated by her strenuous activities while in service, including digging and filling sandbags. In September 2011, he further explained that he believed that due to the Veteran's activities in service she developed deterioration over the years in her upper spine leading to the need for surgery. In November 2010, the Veteran was afforded a VA examination at which the examiner diagnosed degenerative joint and disc disease of her cervical spine. The examiner stated that the chronic, degenerative changes are commonly seen with aging. In January 2011 the examiner completed an addendum medical opinion. The examiner opined that the Veteran's condition was less likely than not caused by her service. The examiner acknowledged the Veteran's report of strenuous activity in service. However, the examiner explained that the Veteran was not seen for neck problems in service, her post-deployment examination was normal, and the Veteran reported her problems with neck pain began in approximately 2000, nine years after service. The examiner opined that it was not likely that problems beginning so long after the Veteran's deployment could be cause by her service. The Board finds the opinion of the VA examiner, who reviewed the Veteran's entire file, and addressed the nearly ten year gap between the Veteran's service and her seeking treatment for upper back pain, is the most probative opinion of record. The Board has considered the opinion of Dr. A. that states that her work in service caused deterioration over the years after service, but finds that his opinion is less probative as he offered no explanation for the large period of time when the record contains no complaints of back pain and in fact, the Veteran denied back problems. The Board acknowledges the Veteran's personal belief that her current upper back problems are due to her service, but finds her opinion has less probative value than that of the opinions of the doctors in this case. Although the Veteran has experience as a nurse, including working on cases that involved orthopedic matters and taking classes on human anatomy and physiology, the question of the etiology of her cervical spine condition is a complicated medical question, particularly considering the Veteran's age and length of time between the Veteran's service and her degenerative joint disease and ultimate knee replacement surgeries. The Board also notes that degenerative joint and disc disease are conditions condition involving seen and unseen system processes that are diagnosed based on specialized imaging, not merely physical observation. The Board further notes that the Veteran has offered little rationale to support her opinion, beyond arguing that she had back pain in service and had not since engaged in such strenuous activity as she had in service. Further, the Board has fully considered her competent and credible assertions of pain in service. However, to the extent that the Veteran would now have the Board believe that her back pain has continued unabated since service, the Board finds that the more contemporaneous evidence suggests her symptoms resolved. Therefore, although degenerative joint disease is a chronic disease, the Board finds that service connection is not warranted on a presumptive basis as it did not manifest to a compensable degree within one year following her separation from service. See 38 C.F.R. §§ 3.307, 3.309 (2013). Further, the condition was not shown to have existed in service nor does the evidence show a continuity of symptomatology since service. See 38 C.F.R. § 3.303(b); Walker, 708 F.3d 1331. The provisions pertaining to a Gulf War undiagnosed illness also do not apply as the Veteran's back problems have been diagnosed as degenerative joint disease and are not due to an undiagnosed illness. Therefore, the Board finds that a preponderance of the evidence is against service connection for an upper back disability, the benefit-of-the-doubt doctrine does not apply, and the claim must be denied. Hand and Thumb The Veteran contends her bilateral hand disability and left thumb metacarpal joint arthrosis are due to sleeping in confining conditions in service. The Veteran was afforded a VA examination in November 2010. She was found to have mild degenerative changes in her right thumb and mild degenerative joint disease in her left hand. The examiner noted that the Veteran reported that her pain resolved after she returned to the United States and returned in the past 10 years. In April 2013 the Veteran underwent another VA examination. The examiner opined that the degenerative changes seen in the Veterans hands were not caused by the Veteran's service or any Gulf War environmental exposure. The examiner explained that degenerative changes is a pathological diagnosis with a known etiology of wear and tear associated with part of the aging process and the Veteran's occupation as a nurse, which involved the use of her hands most of the time. The examiner noted the lack of documentation of bilateral hand problems within the first five years after active duty. The Board notes that the Veteran has also been diagnosed with and is service-connected for fibromyalgia. Arthritis is among the chronic diseases for which service connection may be granted if the disease becomes manifest to a compensable degree within one year following separation from service; however, the arthritis in the Veteran's hands, including her left thumb, was diagnosed well over a decade after service. 38 C.F.R. §§ 3.307, 3.309 (2013). Further, continuity of the condition has not been shown since service. Notably the Veteran herself told the VA examiner her pain resolved after service only to reappear years later. The Board acknowledges the Veteran's complaints that her hands hurt in service. The Board further notes the finding of unavailability of some of the Veteran's service treatment records from her deployment. However, the Board finds the Veteran's report of hand pain in service to be credible, and does not consider the lack of medical records of hand pain to weigh against her current report of hand pain in service. However, the evidence does not suggest that any troubles she had in service are related to her current arthritis. The Board acknowledges the Veteran's personal belief that her arthritis is due to her service. The Board further acknowledges the Veteran's training and experience as a nurse and her reports that she worked on cases that included orthopedic matters and has taken classes on human anatomy and physiology. As the Veteran certainly has some medical training, the Board does not doubt her competence to opine on some medical issues. However, the Board notes that the etiology of the degenerative changes in her hands and left thumb is a complicated medical question involving seen and unseen system processes diagnosed based on specialized imaging, not merely physical observation. The Board finds that the medical doctor who has offered an opinion in this case has greater qualifications to opine as to such a complex etiology question. The Board further notes that the Veteran has offered little rationale to support her opinion. Therefore, the Board finds the Veteran's own etiology opinion has little probative value. Further, service connection is not warranted as a Gulf War undiagnosed illness as the Veteran's bilateral hand condition has been diagnosed as arthritis. Therefore, the Board finds a preponderance of the evidence is against service connection for either left thumb metacarpal joint arthrosis or a bilateral hand disability. As such, the benefit of the doubt doctrine does not apply and the claim must be denied. Headaches The Veteran contends she has a headache condition as a result of her service, to include as due to an undiagnosed Gulf War illness. At her Board hearing the Veteran testified she began having headaches when deployed and the headaches have continued ever since. The Board acknowledges that the RO has issued a formal finding of the unavailability of the Veteran's service treatment records for the period from November 1990 to May 1992. Thus, the Board does not consider the lack of documentation of headaches on official medical records to weigh against the Veteran's claim. However, the Board notes that some service medical records from after the Veteran's deployment are of record. Specifically, the report of medical history forms completed by the Veteran herself in 1991 and 1997 are of record as well as service examinations conducted at the same time. Notably, the Veteran expressly denied frequent or severe headaches on both the 1991 and 1997 forms, although she reported a number of other conditions on the forms suggesting that if she had been experiencing headaches at either time, she would have reported it along with her other conditions. Further, the November 2011 VA examiner stated that the Veteran reported she did not have headaches on active duty but began to have headaches after she returned to the United States, although she could not say exactly when. Therefore, the Board finds that the Veteran's testimony at her Board hearing that she has had a headache condition that began in and has continued since service not to be credible. Although the Veteran is competent to testify as to a readily observable symptom such as a headache, the Board finds that the evidence does not support that she has had a headache condition since service. Not only have the Veteran's statements made in connection with her claim not been consistent, the contemporaneous medical evidence does not suggest an ongoing headache problem since service. Specifically, the Veteran denied headaches in 1991 and 1997 and post-service treatment records do not mention headaches until many years after service. The Board also finds that the evidence does not support that the Veteran's current headache condition is related to her service. The November 2010 examiner opined that the Veteran's headaches are at least as likely as not related to her cervical spine condition, specifically due to muscle tension. As the Veteran's cervical spine condition is not service-connected, secondary service connection for headaches is not applicable. The examiner further stated that she had no reason to believe that the headaches would be related to a specific exposure event experienced by the Veteran in Southwest Asia. To the extent that the Veteran herself has opined that her headaches are due to service, the Board finds that her opinion is less probative than the opinion of the VA examiner. Although the Veteran has experience as a nurse, the record does not indicate she has the experience and training to diagnose or opine as to the etiology of a headache condition, as there are multiple types of headaches that stem from multiple causes, including neurological causes. The Veteran is certainly competent to report having headaches, but the question of causation of headaches requires an understanding of neurology, which involves a complex and nonvisible body system. Further, the Veteran has offered limited rationale to support her opinion, including identifying the type of headaches and a service-related cause, but rather has simply opined that her headaches are related to her service. Therefore, the Board finds that service connection is not warranted on a direct basis. Further, as the Veteran's headaches have been diagnosed as having a definite etiology, the Board finds that service connection as a Gulf War undiagnosed illness is not warranted. Therefore, the Board finds that a preponderance of the evidence is against service connection for chronic headaches, the benefit of the doubt doctrine does not apply, and the claim must be denied. Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. Notice letters were sent to the Veteran in July 2010, September 2010 and October 2012, prior to the initial adjudications of the issues on appeal. The letters informed the Veteran of what information and evidence must be submitted to substantiate the claim, including a description of what information and evidence must be provided by the Veteran and what information and evidence would be obtained by VA. She 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 letters also addressed VA's practices in assigning disability evaluations and effective dates for those evaluations. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Board finds that 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). The undersigned VLJ who conducted the July 2014 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 Veterans of Foreign Wars, and the VLJ and the representative asked questions regarding the nature and etiology of the Veteran's claimed conditions. In addition, the 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 her 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). In cases where the Veteran's service treatment records are, through no fault of his own, unavailable, a heightened duty exists to assist the Veteran in the development of the case. See O'Hare v. Derwinski, 1 Vet. App. 365 (1991); Layno v. Brown, 6 Vet. App. 465, 469 (1994) (where the Veteran's service treatment records have been destroyed or lost, there is a duty to advise the Veteran to obtain other forms of evidence). In May 2013 the Veteran was informed that her Army Reserves records were incomplete. The RO issued a formal finding of unavailability in June 2013. The RO has otherwise obtained all available service treatment records, VA treatment records, and private treatment records identified by the Veteran. 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 Board thus finds that all necessary development has been accomplished. 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 Veteran was afforded a VA medical examination in November 2010 with respect to her headaches, spine, knees, and fingers. An addendum medical opinion was provided by the VA examiner in January 2011. VA foot and hand examinations were conducted in April 2013. A Gulf War examination was conducted in April 2014. The Veteran has argued that the November 2010 VA examiner was not an orthopedic specialist and did not adequately examiner her spinal condition. However, the Board finds the examiner, a medical doctor, was qualified to perform the examination. VA satisfies its duty to assist when it provides a medical examination performed by a person who is qualified through education, training, or experience to offer medical diagnosis, statements, or opinions able to provide competent medical evidence. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007). The Board further finds that the VA examiner's examination, and more importantly, her etiology opinion was adequate. The Board notes that contrary to the Veteran's contentions, the examiner did note the Veteran's altered gait due to her recent surgery and her reduced range of motion in her back. Regardless, the Board finds that the examiner's etiology opinion was based on an accurate understanding of the facts. The Board finds that for each of the examinations, the examiners obtained an accurate history, listened to the Veteran's assertions, and performed the necessary tests. The Board finds the VA examinations were thorough and adequate and provide a sound basis upon which to base a decision with regard to the Veteran's claim. 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). 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 (2002). ORDER Service connection for right knee degenerative joint disease with total knee arthroplasty is denied. Service connection for left knee degenerative joint disease with total knee arthroplasty is denied. Service connection for upper back disability is denied. Service connection for left thumb metacarpal joint arthrosis is denied. Service connection for bilateral hand condition is denied. Service connection for chronic headaches is denied. REMAND Feet The Veteran contends she is entitled to service connection for bilateral pes planus with bilateral first metatarsophalangeal joint degenerative joint disease and bunionectomies. A veteran who served after December 31, 1946, is presumed to be in sound condition when he or she entered into military service, except for conditions noted on the entrance examination, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1111, 1132. The Veteran does not dispute that she had mild pes planus, as noted on her September 1989 examination, at the time she entered active service. However, she contends that the condition was asymptomatic prior to service and her service permanently aggravated her bilateral foot condition. A pre-existing injury or disease will be considered to have been aggravated during service when there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. 38 C.F.R. § 3.306(b). The presumption of aggravation applies only when pre-service disability increases in severity during service. Beverly v. Brown, 9 Vet. App. 402, 405 (1996). Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted to symptoms, is worsened. Jensen v. Brown, 4 Vet. App. 304, 306-307 (1993) (citing Hunt v. Derwinski, 1 Vet. App. 292 (1991)). Records indicate that the Veteran was treated for a blister on her left great toe in February 1991 and also had a callous off of her left toe. She was on profile to wear sneakers. In April 1991, just prior to the Veteran's release from active duty, an examination noted the Veteran had bilateral pes planus, flexible, and asymptomatic. She did not report foot trouble on her accompanying report of medical history. She also did not report foot trouble on a February 1997 report of medical history, and her pes planus was again noted to be mild and asymptomatic on the accompanying examination conducted as part of the Veteran's service in the Reserves. The Veteran's daughter has submitted a statement in which she recalled her mother complaining of foot pain while deployed as well as after service. The Veteran testified at her Board hearing that when she left active service her foot pain had subsided as she was no longer doing strenuous labor, although she noted she was taking over the counter pain medication. A private treatment note reflects that the Veteran had an initial orthopedic consultation with regard to her left foot in May 2001, reporting pain for several weeks. She reported the pain was worse with weight bearing and walking and she was experiencing significant pain at work. She was noted to have a flexible pronated flat foot deformity. In July 2001 after the Veteran reported continued left foot and ankle pain, a diagnosis of left foot severe pes planus was noted. Significant pes planus, especially on the left, in the weightbearing position was again noted in February 2006 after the Veteran sought treatment for left ankle pain. She reported long-standing flat foot problems. In an October 2010 statement one of the Veteran's private physicians, Dr. C, opined that it is more likely than not that the Veteran's foot problems and left ankle problem were permanently aggravated in service. He recounted her report of having foot pain after engaging in strenuous activities while deployed, including developing calluses. In August 2011 he further explained that there is "probably evidence of aggravation, excessive pressure, strain and injury to her feet" in service, which resulted in anatomical changes in the structure of her feet, which contributed to bilateral bunion deformities and degenerative joints in her mid-feet. The Veteran was afforded a VA examination in November 2010. The examiner opined that it is less likely than not that the Veteran's bilateral foot condition is related to her service. The examiner explained that it is not at least as likely as not that the Veteran's transient problems with foot soreness in service constituted a medical condition severe enough to cause her to require foot surgery many years later. The examiner opined that it is more likely that the Veteran's foot condition is a result of her career as an operating room nurse, which requires prolonged standing. In January 2011 another VA opinion was obtained. The examiner reviewed the record and concluded that the Veteran's bilateral pes planus was not permanently aggravated during her service nor were her bilateral first metatarsophalangeal joint degenerative joint disease and bunionectomies caused or aggravated by her service. The examiner opined that it is unlikely that the Veteran's service activities were so much at variance with her usual daily and occupational tasks as to be identifiable as the cause of her chronic foot problems. The examiner noted that the time the Veteran spent setting up and taking down the installation was likely no more than a week or so on either end of her deployment and primarily involved lifting and carrying. The examiner noted that the Veteran's flat feet were found asymptomatic on examination at her separation from active service and she herself did not report lameness or foot pain. The examiner further noted that in May 2001 when the Veteran sought treatment for foot pain, she reported several weeks of left foot pain, which corresponds to 10 years after the Veteran's deployment. In April 2013 the Veteran underwent another VA examination. The examiner opined that it is less likely than not that the Veteran's documented callus and blister in service aggravated her bilateral pes planus. The examiner noted the lack of documentation of ongoing bilateral foot problems in the first five to 10 years after service and in fact her denial of foot problems on service examinations in April 1991 and February 1997. The examiner noted that the Veteran was activated for no longer than six months and opined that most of her aggravation of her feet and ankles took place over many years during her employment as a nurse, which required a lot of standing. The Veteran has stated that at the time of her service separation examination she had not performed any strenuous activity for two months and had treated her pain with medication, explaining the lack of symptoms noted at that time. She further has noted that after service she took several years off from working and then returned to work part time as a nurse in a position that did not require being on her feet for long periods of time. The Veteran has contended that the foot calluses she had during service were a form of aggravation of her feet as callus and bunion development in individuals with flat feet are documented. In support of her opinion she submitted an Internet printout in July 2015 noting that calluses can be caused due to uneven distribution of pressure by the toes and are often seen in flatfooted patients. As previously requested by the RO, the Board is remanding to obtain an supplemental VA opinion as to whether the Veteran's in-service treatment for calluses was at least as likely as not evidence of aggravation of her bilateral pes planus during service. As there is medical opinion evidence suggesting that the Veteran's right foot claw toe deformities and right gastrocnemius contracture are secondary to her pes planus, the Board finds that the issues of entitlement to service connection for those disabilities must also be remanded as the issues are intertwined with the issue of entitlement to service connection for pes planus. SOC In a December 2014 rating decision the RO granted service connection for bilateral tendinitis, carpal tunnel syndrome, and ulnar nerve entrapment and awarded a 10 percent rating. In her August 2015 appellate brief, the Veteran expressed disagreement with the rating assigned. Therefore, the RO must issue an SOC on the issue. See Manlincon v. West, 12 Vet. App. 238 (1999). Upon receipt of the SOC, the Veteran will then have an opportunity to complete the steps necessary to perfect her appeal of the claim to the Board by filing a timely substantive appeal (e.g., a VA Form 9 or equivalent statement). 38 C.F.R. §§ 20.200, 20.202, 20.300, 2.301, 20.302, 20.303, 20.304, 20.305. Accordingly, these matters are REMANDED for the following action: 1. Send the Veteran a Statement of the Case concerning her claim for a higher initial rating for bilateral tendinitis, carpal tunnel syndrome and ulnar nerve entrapment. If, and only if, she submits a timely substantive appeal in response to the SOC, thereby perfecting her appeal as to the claim, should it be returned to the Board for further appellate consideration. 2. Obtain a supplemental VA medical opinion from the April 2013 VA examiner, or if unavailable, another suitably qualified examiner, as to whether the Veteran's in-service treatment for calluses was at least as likely as not evidence of aggravation of her bilateral pes planus during service. If the examiner concludes that the Board's question cannot be answered without an examination, one should be scheduled. A copy of this remand and the Veteran's claims file should be made available to the examiner. A complete rationale should be provided for any opinion expressed. 3. Thereafter, readjudicate the Veteran's pending claims in light of any additional evidence added to the record. If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. Thereafter, the case should be returned to the Board for appellate review. 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 2014). ______________________________________________ M. TENNER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs