Citation Nr: 1751187 Decision Date: 11/08/17 Archive Date: 11/17/17 DOCKET NO. 09-49 303 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUES 1. Entitlement to service connection for a low back disability. 2. Entitlement to service connection for a bilateral foot disability other than tylomata of the feet. 3. Entitlement to special monthly compensation (SMC) by reason of being housebound. REPRESENTATION Appellant represented by: Christina A. Clark, Agent WITNESS AT HEARING ON APPEAL Appellant (Veteran) ATTORNEY FOR THE BOARD C. Ferguson, Counsel INTRODUCTION The Veteran, who is the appellant, had active service in the U.S. Army from September 1966 to September 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In October 2011, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing. A transcript of the hearing is of record. In February 2012, the Board dismissed the issue of service connection for a lung disorder, including emphysema, due to a request for withdrawal of the appeal. The Board also denied service connection for peripheral neuropathy of the lower extremities and the left arm, reopened service connection for a low back disability and bilateral foot disabilities, and denied non-service-connected pension benefits. The Board remanded the issues of service connection for a low back disability and bilateral foot disabilities, and residuals of a left thigh boil excision, as well as SMC by reason of being housebound, for VA examinations with medical opinions, and subsequent readjudication of the appeal. Pursuant to the Board's remand directives, the April 2017 VA examinations with medical opinions were provided. In consideration thereof, the Board finds that there has been compliance with the Board's prior remand directives. Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008). During the course of remand and as a result of the ordered development, service connection was established for tylomata (calluses) of the right foot, tylomata (calluses) of the left foot, and a scar of the left lower thigh as a residual of the boil infection; therefore, the issue of service connection for residuals of a left thigh boil excision has fully resolved in the Veteran's favor and is no longer before the Board. See April 2017 rating decision. The issue of entitlement to service connection for ischemic heart disease, including as due to herbicide exposure, has been perfected, but not yet certified to the Board. After review of the record, it is unclear whether the Agency of Original Jurisdiction (AOJ) is still taking action on the issue. As such, the Board will not accept jurisdiction over them at this time, but it will be the subject of a subsequent Board decision, if otherwise in order. The issue of entitlement to special monthly compensation by reason of the need for the aid and attendance of another has been raised by the Veteran, but has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. A low back disability was not noted at service entrance and did not clearly and unmistakably exist prior to active service. 2. Low back pain was manifested during service. 3. The current low back disability was not manifested until many years after service and is not causally or etiologically related to service. 4. Metatarsalgia was manifested during service and recurred after service separation. 5. There was no foot injury or disease during service and chronic symptoms of arthritis of the feet were not manifested during service. 6. Symptoms of arthritis of the feet have not been continuous since service separation, and arthritis did not manifest to a compensable degree in the year following separation from service. 7. The arthritis of the feet was manifested many years after service and is not causally or etiologically related to service. 8. Tinea pedis was not manifested during service. 9. Tinea pedis was manifested many years after service and is not causally or etiologically related to service. 10. For the period from September 20, 2007, service connection has been in effect for posttraumatic stress disorder, rated at 70 percent; tylomata (calluses) of the right foot, rated at 0 percent; tylomata (calluses) of the left foot, rated at 0 percent; and scar of the left lower thigh as a residual of the boil infection, rated at 0 percent. A TDIU has also been in effect. 11. For the period from September 20, 2007, the Veteran does not have a single service-connected disability rated at 100 percent and additional service-connected disability or disabilities independently ratable at 60 percent. 12. From November September 20, 2007, the Veteran is not permanently housebound by reason of service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disability are not met. 38 U.S.C.A. §§ 1110, 1112, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 2. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for metatarsalgia are met. 38 U.S.C.A. §§ 1110, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2017). 3. The criteria for service connection for degenerative arthritis of the feet and tinea pedis are not met. 38 U.S.C.A. §§ 1110, 1112, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 4. The criteria for SMC by reason of being housebound are not met. 38 U.S.C.A. §§ 1114, 5103A, 5107 (West 2014); 38 C.F.R. § 3.350 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) enhanced VA's duties to notify and assist claimants in substantiating their claims for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). Proper notice from VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 C.F.R. § 3.159(b)(1). This notice should be provided prior to an initial unfavorable decision on a claim by the RO. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The United States Court of Appeals for Veterans Claims (Court) issued a decision in the appeal of Dingess v. Nicholson, 19 Vet. App. 473 (2006), which held that the 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, including the degree of disability and the effective date of an award. Those five elements include: (1) veteran status; (2) existence of a disability; (3) a connection between a veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. In the April 2008 notice letter sent prior to the initial denial of the claims, the RO advised the Veteran of what the evidence must show to establish entitlement to service-connected compensation and SMC benefits, and described the types of information and evidence that the Veteran needed to submit to substantiate the claims. The RO also explained what evidence VA would obtain and make reasonable efforts to obtain on the Veteran's behalf in support of the claims. The RO further informed the Veteran how VA determines the disability rating and effective date once service connection is established. In consideration of the foregoing, the Board finds that the VCAA notice requirements were fully satisfied prior to the initial denial of the claims, and there is no outstanding duty to inform the Veteran that any additional information or evidence is needed. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the VLJ who conducts a hearing (1) fully explain the issues and (2) suggest the submission of evidence that may have been overlooked. At the Board hearing, the VLJ identified the issues on appeal and posed questions in order to elicit testimony regarding the alleged in-service injury or disease, and past and current symptoms, diagnoses, and treatment for the claimed disabilities for which he sought service-connected disability benefits and SMC housebound. As a result of the hearing testimony, the Board remanded the issues on appeal for VA examinations with medical opinions. In consideration of the foregoing, the Board finds that the duties under 38 C.F.R. § 3.103(c)(2) were met. Regarding VA's duty to assist in claims development, the record contains all available evidence pertinent to the appeal. VA has requested records identified throughout the claims process. The Veteran was given appropriate notice of the responsibility to provide VA with any treatment records pertinent to the appeal, and the record contains sufficient evidence to make a decision on the appeal. The complete service treatment records are included in the record, and post-service treatment records identified as relevant to the appeal have been obtained or otherwise submitted. In April 2017, the RO provided VA examinations. The collective VA examination reports include all relevant findings and medical opinions needed to evaluate fairly the appeals. The April 2017 VA examiner considered an accurate history of the claimed disabilities as provided through interview of the Veteran and review of the record, as well as the Veteran's subjective complaints as it related to the current symptomatology and its effects on daily life and performed thorough examinations; therefore, the VA examiners had adequate facts and data regarding the history and condition of the claimed disabilities when providing the medical opinions. For these reasons, the Board finds that the VA examination reports are adequate, and there is no need for further VA examination or medical opinion. The Veteran has not made the RO or the Board aware of any other evidence relevant to the appeal that needs to be obtained. Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed, and no further development is required. Service Connection Legal Criteria 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; 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). As a general matter, 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). The Veteran is currently diagnosed with degenerative disc disease, tinea pedis, degenerative arthritis of the feet, and metatarsalgia of the feet. Arthritis is a "chronic disease" under 38 C.F.R. § 3.309(a); therefore, the Board finds that the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are applicable to that diagnosis. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Degenerative disc disease, tinea pedis, and metatarsalgia of the feet are not "chronic diseases" under 38 C.F.R. § 3.309(a); therefore, the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service are not applicable to those diagnoses. Walker, 708 F.3d 1331. For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). In addition, the law provides that, where a veteran served ninety days or more of active service, and certain chronic diseases, such as arthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such 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 (West 2014); 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. A veteran is presumed to have been in sound condition when examined, accepted, and enrolled for service except as to defects, infirmities, or disorders noted at the time of examination, acceptance, enrollment, 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 (West 2014); 38 C.F.R. § 3.304 (2017). If a disorder was not noted on entering service, the government must show clear and unmistakable evidence of both a preexisting condition and a lack of in-service aggravation to overcome the presumption of soundness. Wagner v. Principi, 370 F.3d 1089, 1096-97 (Fed. Cir. 2004). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has held that the correct standard for rebutting the presumption of soundness under 38 U.S.C.A. § 1111 requires the government to show by clear and unmistakable evidence that (1) the veteran's disability existed prior to service and (2) that the pre-existing disability was not aggravated during service. If the government meets this burden, the presumption of soundness under 38 U.S.C.A. § 1111 is rebutted, and the veteran is not entitled to service-connected benefits. If the government fails to rebut the presumption of soundness under 38 U.S.C.A. § 1111, a veteran's claim is one for direct service connection. Wagner, 370 F.3d at 1097. In explaining the meaning of an increase in disability, the Court has held that "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." Hunt v. Derwinski, 1 Vet. App. 292, 297 (1992); see also Davis v. Principi, 276 F.3d 1341, 1346 (Fed. Cir. 2002) (explaining that, for non-combat veterans, a temporary worsening of symptoms due to flare ups is not evidence of an increase in disability). In determining whether a condition preexisted service, a veteran's medical history, accepted medical principles, evidence regarding the basic character, origin, and development of the condition, and lay and medical evidence concerning the inception, development, and manifestations of the condition must be considered. 38 C.F.R. § 3.304 (b); see Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). Service Connection Analysis for Low Back Disability Preliminarily, the Board finds that a low back disability did not exist prior to service. Because a low back disability was not noted at service entrance, the presumption of sound condition as it relates to lumbar degenerative disc disease is applicable. While some evidence of record suggests that a low back disability may have existed prior to active service, the presumption of soundness has not been rebutted by the high evidentiary burden of clear and unmistakable evidence, so the Board will consider whether a low back disability was incurred during service in this case. 38 U.S.C.A. § 1111; 38 C.F.R. §§ 3.303, 3.304. After review of all the lay and medical evidence of record, the Board finds that there was recurrent back pain and a back injury (i.e., back strain) during service, but no chronic symptoms of arthritis during service. During service, in May 1967, the Veteran reported back trouble. In June 1967 and November 1967, the Veteran complained of low back pain and service radiographic reports showed a normal lumbosacral spine at those times. The November 1967 service treatment entry notes that there were no objective findings to account for the low back pain symptoms. In November 1967, the Veteran was treated for back strain. In December 1967, the Veteran reported soreness in the back, denied back injury, and reported back pain with prolonged walking or lifting. An undated service radiographic report shows that the Veteran reported a three year history of low back pain with normal x-ray of the thoracic and lumbosacral spine. On the September 1968 service separation examination report of medical history, the Veteran checked "Yes" when asked if he then had or had ever had back trouble of any kind. The weight of the evidence is against finding that the current low back disability had its onset during service or is otherwise causally or etiologically related to service. At the September 1968 service separation examination, the spine and musculoskeletal system were clinically evaluated as normal. The earliest diagnosis of a low back disability is in 1995, approximately 27 years after service. See December 1995 VA radiology report (noting an impression of stable lumbosacral spine with mild degenerative disk disease). Prior to 1995, the evidence showed diagnoses of chronic and/or mechanical low back pain. The gap of approximately 27 years between service and the onset of a low back disability, is one factor, along with other factors in this case - including normal physical examinations and x-rays of the low back during service, a normal spine examination at service separation, and post-service onset of symptoms of the current low back disability many years after service - that tends to weigh against a finding of service incurrence. See Buchanan v. Nicholson, 451 F.3d 1336 (Fed. Cir. 2006) (the lack of contemporaneous medical records is one fact the Board can consider and weigh against the other evidence, although the lack of such medical records does not, in and of itself, render the lay evidence not credible); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and evidence of a claimed disability is one factor to consider as evidence against a claim of service connection). Also, after review of all the record and interview and examination of the Veteran, the April 2017 VA examiner opined that it was less likely than not that the low back disability was incurred in or caused by service. In support of the medical opinion, the April 2017 VA examiner explained that, while the Veteran reported subjective symptoms, there was no clinical or radiographic evidence of a lumbar or thoracic condition in service. The April 2017 VA examiner stressed that this was the consensus among the service medical providers, and noted that one of the service medical providers was an orthopedic specialist. The April 2017 VA examiner wrote that, since service separation, the Veteran had been diagnosed with lumbar degenerative disc disease in the context of aging, occupational demands, obesity, and possible trauma. The April 2017 VA examiner reiterated that the current back was less likely as not incurred in or caused by the complaints of back pain and cited the normal x-ray, normal physical examination, and report of no recent trauma involving the low back during service. The April 2017 VA examiner had adequate facts and data on which to base the medical opinion and provided a sound rationale for the medical opinion; therefore, the April 2017 VA medical opinion is of significant probative value. There is no competent medical opinion to the contrary of record. Although the Veteran has asserted that the current low back disability is causally related to service, he is a lay person and, under the specific facts of this case, does not have the requisite medical expertise to be able to diagnose degenerative disc disease or render a competent medical opinion regarding its cause where the facts show back pain during service with normal examination and x-ray, recurrent mechanical back pain for many years after service, and no evidence of degenerative disc disease symptoms until many years after service. Degenerative disc disease is complex and involves unseen systems processes and disease processes, some of which are not observable by the five senses of a lay person, includes various possible etiologies, only one of which involves trauma to a joint, and is diagnosable only by X-ray or similar specific specialized clinical testing; therefore, under the facts presented in this case, the Veteran is not competent to diagnose degenerative disc disease or to opine as to its etiology. Thus, while the Veteran is competent to report back symptoms that he experienced at any time, he is not competent to opine on whether there is a link between the lumbar degenerative disc disease, which was manifested many years after service separation, and active service because such diagnosis and nexus require specific medical knowledge and training. King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2009) (holding that it was not erroneous for the Board to find that a lay veteran claiming service connection for a back disorder and his wife lacked the "requisite medical training, expertise, or credentials needed to render a diagnosis" and that their testimony "could not establish medical causation nor was it a competent opinion as to medical causation"); Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (holding that ACL injury is "medically complex" for lay diagnosis); Clyburn v. West, 12 Vet. App. 296, 301 (1999) (holding that a veteran is not competent to relate currently diagnosed chondromalacia patellae or degenerative joint disease to the continuous post-service knee symptoms); Savage v. Gober, 10 Vet. App. 488, 496-97 (1997) (requiring that a veteran present medical nexus evidence relating currently diagnosed arthritis to in-service back injury). For these reasons, the Veteran's purported opinion that the current low back disability is the result of service is of no probative value. Thus, in consideration of the foregoing, the Board finds that a preponderance of the lay and medical evidence that is of record weighs against service connection for a low back disability; therefore, the appeal must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. Service Connection Analysis for Bilateral Foot Disability Other Than Tylomata After review of all the lay and medical evidence of record, the Board finds that the evidence is in equipoise on the question of whether the current metatarsalgia had its onset during service and recurred after service. See Dorland's Illustrated Medical Dictionary 1138 (30th ed. 2003) (defining metatarsalgia as pain and tenderness in the metatarsal region); see also Medlineplus website at https://www.mayoclinic.org/diseases-conditions/metatarsalgia/symptoms-causes/syc-20354790?p=1 (noting that symptoms of metatarsalgia can include sharp, aching or burning pain in the ball of the foot and pain that worsens with standing, running, flexing the foot, and walking). During service, in December 1967, the Veteran complained of soreness in the feet, including with prolonged walking. Later, in July 1968, the Veteran received treatment for calluses for the soles of the feet, which indicates repeated pressure or friction on the sole of the foot and tends to provide further support for the presence of metatarsalgia during service. On the September 1968 service separation report of medical history, the Veteran checked "Yes" when asked if he then had or had ever had foot trouble. At the April 2017 VA examination, the Veteran competently reported that the same symptoms of foot pain affecting the sole of the foot recurred after service separation, and there is no indication in the record that the account is not credible. Rather, the lay and medical evidence contemporaneous to service showing complaint of bilateral foot pain and treatment of calluses on the sole of the foot during service and the report of foot trouble at service separation is evidence that tends to support the Veteran's account; therefore, the account of recurrent symptoms of bilateral foot pain since service is of significant probative value. Although the April 2017 VA examiner opined that metatarsalgia was due to a combination of factors including arthritis associated with aging and the effects of loading due to chronic obesity, the medical opinion is of minimal probative value and is outweighed by the other evidence discussed above because the April 2017 VA examiner did not take into account the evidence of bilateral foot pain during service and recurrent foot pain since service. In consideration thereof, and resolving reasonable doubt in favor of the Veteran, the criteria for service connection for metatarsalgia under 3.303(d) have been met. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. After review of the lay and medical evidence of record, the Board finds that the weight of the evidence is against a finding of a foot injury or disease during service, tinea pedis or symptoms of tinea pedis during service, or chronic symptoms of arthritis of the feet during service. The service treatment records, which are complete, are absent of any report, complaint, diagnosis, or treatment for foot problems other than calluses and report of foot pain, which are now attributed to metatarsalgia for reasons explained above. At the September 1968 service separation examination, the feet and skin were clinically evaluated as normal. On the September 1968 service report of medical history, the Veteran checked "Yes" when asked if he then had or had ever had foot trouble but simultaneously checked "No" when asked if he then had or had ever had arthritis or rheumatism, or skin diseases; thus, it is reasonable to infer that the foot trouble referenced by the Veteran at service separation did not include arthritis or a skin disease such as tinea pedis. The weight of the evidence is against a finding of continuous symptoms of arthritis of the feet since service, including to a compensable degree within one year of service separation. The earliest evidence of degenerative arthritis of the feet is in 2013, approximately 45 years after service. See 38 C.F.R. § 4.71a, Diagnostic Code 5003 (rating degenerative arthritis established by x-ray findings). The gap of approximately 45 years between service and the onset of arthritis of the feet in this case is one factor -- along with other factors that include no in-service foot injury or disease and affirmative post-service history of post-service onset of symptoms -- that tends to weigh against a finding of continuous symptoms of arthritis of the feet after service separation. See Buchanan, 451 F.3d at 1336; see also Maxson, 230 F.3d at 1333. As the weight of the evidence demonstrates no "continuous" symptoms of arthritis of the feet since service, including to a compensable degree within the first post-service year, the criteria under 38 C.F.R. § 3.303(b) for presumptive service connection based on "continuous" symptoms of arthritis of the feet manifested to a degree of ten percent within one year of service separation are not met. 38 C.F.R. §§ 3.307, 3.309. The weight of the evidence is against a finding that tinea pedis or arthritis of the feet was otherwise causally or etiologically related to service. The earliest evidence of tinea pedis is in 1985, approximately 17 years after service. During the course of receiving VA treatment for tinea pedis in July 1985, the Veteran reported that tinea pedis symptoms had begun during service; however, the account is inconsistent with the lay and medical evidence contemporaneous to service showing no skin diseases affecting the feet (other than calluses), and post-service evidence showing no tinea pedis symptoms until many years after service. The gap of approximately 17 years between service and the onset of arthritis of the feet in this case is one factor -- along with other factors that include no in-service skin disease affecting the feet and affirmative post-service history of post-service onset of tinea pedis symptoms -- that tends to weigh against a finding of service incurrence. See Buchanan at 1336; see also Maxson at 1333. After reviewing the record and interview and examination of the Veteran, the April 2017 VA examiner provided a negative opinion on the question of whether tinea pedis or degenerative arthritis of the feet were related to service. In support of the medical opinion, the April 2017 VA examiner noted that the service treatment records were absent of evidence of tinea pedis, and tinea pedis was diagnosed in 1986 and 1998 (i.e., many years after service). The April 2017 VA examiner attributed the arthritis of the feet to aging and the effects of loading secondary to chronic obesity. The April 2017 VA examiner had adequate facts and data on which to base the medical opinion and provided a sound rationale for the medical opinion; therefore, the April 2017 VA medical opinion is of significant probative value. There is no competent medical opinion to the contrary of record. Although the Veteran has asserted that the current degenerative arthritis of the feet and tinea pedis are causally related to service, he is a lay person and, under the specific facts of this case, does not have the requisite medical expertise to be able to diagnose the arthritis of the feet or render a competent medical opinion regarding its cause where the facts show no in-service foot injury or disease, no skin disease affecting the feet (other than calluses), and no feet arthritis symptoms were manifested until many years after service. Arthritis is complex and involves unseen systems processes and disease processes that are not observable by the five senses of a lay person, and includes various possible etiologies, and is diagnosable only by X-ray or similar specific specialized clinical testing; therefore, under the facts presented in this case, the Veteran is not competent to diagnose arthritis of the feet or to opine as to its etiology. While the Veteran is competent to relate symptoms of foot pain that he experienced at any time, he is not competent to opine on whether there is a link between the arthritis of the feet, which was manifested many years after service separation, and active service because such diagnosis and nexus require specific medical knowledge and training. Although the Veteran is competent to report skin symptoms on the feet, the account of tinea pedis symptoms during service and recurrent tinea pedis symptoms after service is not deemed credible, so is of no probative value. The lay account is outweighed by the evidence of tinea pedis many years after service and unrelated to service. For these reasons, the Veteran's purported opinion that the current arthritis of the feet and tinea pedis are the result of service is of no probative value, and that a preponderance of the lay and medical evidence that is of record weighs against service connection for arthritis of the feet and tinea pedis; therefore, the appeals as it relates to those diagnoses must be denied. See 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. SMC Housebound Additional compensation on the basis of being housebound is provided where a veteran (1) has, in addition to a single, permanent service-connected disability rated 100 percent disabling, additional service-connected disability or disabilities independently evaluated as 60 percent or more disabling which are separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems, or (2) is permanently housebound by reason of service-connected disability or disabilities. A veteran will be considered housebound where the evidence shows that, as a direct result of the service-connected disability or disabilities, he or she is substantially confined to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his or her lifetime. 38 U.S.C.A. § 1114(s); 38 C.F.R. § 3.350. The Veteran seeks SMC based on housebound status. Throughout the period at issue (i.e., from September 20, 2007, forward), service connection has been in effect for posttraumatic stress disorder, rated at 70 percent; tylomata (calluses) of the right foot, rated at 0 percent; tylomata (calluses) of the left foot, rated at 0 percent; and scar of the left lower thigh as a residual of the boil infection, rated at 0 percent. For reasons explained above, service connection has now been established for metatarsalgia; however, the Board does not have the authority to assign an initial disability rating in the first instance. Nonetheless, the Board will assume that the now service-connected metatarsalgia is assigned a (maximum) 10 percent rating under the criteria at 38 C.F.R. § 4.71a, Diagnostic Code 5279, for unilateral or bilateral anterior (Morton's disease) metatarsalgia solely for the purposes of this SMC adjudication. The Veteran is also in receipt of a TDIU for the entire period. After review of the lay and medical evidence of record, the Board finds that the criteria for SMC by reason of being housebound have not been met or approximated for any period. The evidence shows the Veteran was not housebound due to any service-connected disability at any time during the period. The Veteran was neither substantially confined to his dwelling and the immediate premises nor institutionalized as a result of the service-connected PTSD or any other service-connected disability for any period. Furthermore, although the award of a TDIU was based on the severity of PTSD symptoms and functional impairment, the other service-connected disabilities are not independently ratable at 60 percent. Rather, the combined rating for the other service-connected disabilities would be no more than 10 percent. For these reasons, the Board finds that the criteria for entitlement to SMC by reason of being housebound have not been met, and the appeal must be denied. ORDER Service connection for a low back disability is denied. Service connection for metatarsalgia of the feet is granted. SMC by reason of being housebound is denied. ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs