Citation Nr: 1804128 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 08-25 603 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for prostate cancer. 2. Entitlement to service connection for posttraumatic stress disorder (PTSD). 3. Entitlement to service connection for a left knee disability. 4. Entitlement to service connection for a right knee disability, including as secondary to the left knee disability. 5. Entitlement to service connection for a low back disability, including as secondary to the left knee disability. 6. Entitlement to service connection for bilateral athlete's foot. 7. Entitlement to service connection for diabetes mellitus, type II. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Jonathan Z. Morris, Associate Counsel INTRODUCTION The Veteran had active military service from March 1976 to September 1979, with additional service in the Army National Guard, including on active duty for training (ACDUTRA) from June to November 1973. This appeal to the Board of Veterans' Appeals (Board/BVA) is from April 2007, March 2010, September 2010, and February 2011 rating decisions by Department of Veterans Affairs (VA) Regional Offices (ROs). In February 2014, the Veteran testified before the undersigned Veterans Law Judge during a Travel Board hearing. A transcript of the proceeding is of record. This case was last before the Board in July 2014, when the Board determined that new and material evidence had been received sufficient to reopen the Veteran's service connection claim for diabetes mellitus. The Board then proceeded to remand this claim and the others for further development. Upon completion of that development, the Agency of Original Jurisdiction (AOJ) continued to deny these claims, as reflected in an April 2016 Supplemental Statement of the Case (SSOC), and since has returned these claims to the Board for further appellate review. There was compliance, certainly the acceptable substantial compliance, with the Board's remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions); but see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only "substantial" rather than strict or exact compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999). FINDINGS OF FACT 1. Resolving all reasonable doubt in favor of the Veteran, his bilateral athlete's foot disability is etiologically related to his active military service. 2. The Veteran's current left knee disability is not shown to have had its onset during service, or to be causally or etiologically related to any disease, injury, or incident in service, and did not manifest within one year of his separation. 3. The most probative medical evidence of record does not establish that his right knee disability or low back disability were incepted during service, or manifested to a compensable degree within a year of his discharge from service, or are otherwise related or attributable to any disease, injury, or incident of his service - including caused or aggravated by a service-connected disability. 4. The Veteran does not have a diagnosis of PTSD based on a claimed credible stressor, he did not engage in combat with the enemy, and there is no credible evidence corroborating his alleged in-service stressor. 5. The preponderance of the evidence is against a finding that the Veteran's diabetes mellitus is etiologically related to his active military service. 6. The preponderance of the evidence is against a finding that the Veteran's prostate cancer is etiologically related to his active military service. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran's favor, the criteria for service connection for bilateral athlete's foot have been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 2. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). 3. The criteria for service connection for a right knee disability, including as secondary to the left knee disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). 4. The criteria for service connection for a low back disability, including as secondary to the left knee disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2017). 5. The criteria for service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.102, 3.303, 3.304 (2017). 6. The criteria for service connection for diabetes mellitus type II have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (West 2014); 38 C.F.R. § 3.102, 3.303, 3.304 (2017). 7. The criteria for service connection for prostate cancer have not been met. 38 U.S.C. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has duties to notify and assist a claimant in substantiating a claim for VA benefits. 38 U.S.C. §§ 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 or her representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. 38 U.S.C. § 5103 (a); 38 C.F.R. § 3.159 (b); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Ideally, 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). In a March 2005 letter, the Veteran was informed of what evidence was required to substantiate his claims, and of his and VA's respective responsibilities in obtaining evidence. Additionally, this letter notified the Veteran of the criteria for assigning a disability rating and an effective date. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The Veteran was also afforded ample notice of the applicable law and requirements for substantiating his claims in the October 2005, December 2011, and January 2012 SOCs, as well in additional SSOCs. He has had ample opportunity to respond or supplement the record, and has not alleged that any notice was less than adequate. Thus, the Board finds that VA's duty to notify is satisfied. Regarding the duty to assist, the Board notes that the claims file contains the Veteran's service treatment records (STRs), relevant post-service medical records, buddy statements, and the Veteran's own written statements. Neither the Veteran nor his representative has identified, nor does the record otherwise indicate, any other evidence relevant to his claim that is obtainable and has not been obtained. Furthermore, the Veteran was afforded VA compensation examinations and opinions were provided in support of his claim. Upon review of the medical evidence, the Board concludes that these examination reports and the other medical records in the file, collectively, provide the information needed to render a decision in this case. 38 C.F.R. § 4.2; Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claim. Therefore, no further assistance to the Veteran with the development of evidence is required. II. Legal Criteria for Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, to successfully establish service connection, there must be competent and credible evidence showing (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the current disability and the disease or injury incurred in or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain "chronic diseases" may be presumed to have been incurred in or aggravated by service if they manifest to a degree of 10 percent or more within one year of a Veteran's separation from service. 38 C.F.R. §§ 3.307, 3.309(a). This presumption is rebuttable by probative evidence to the contrary. Id. When a chronic disease is shown in service, sufficient to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). To be "shown in service," the disease identity must be established and the diagnosis must not be subject to legitimate question. Walker v. Shinseki, 708 F.3d 1331, 1335 (Fed. Cir. 2013); see also 38 C.F.R. § 3.303(b). There is no "nexus" requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease. Walker, 708 F.3d at 1336. Service connection may also be granted on a secondary basis for a condition that is not directly caused by the Veteran's service. 38 C.F.R. § 3.310. In order to prevail under a theory of secondary service connection, the evidence must demonstrate an etiological relationship between (1) a service-connected disability or disabilities and (2) the condition said to be proximately due to the service-connected disability or disabilities. Buckley v. West, 12 Vet. App. 76, 84 (1998); see also Wallin v. West, 11 Vet. App. 509, 512 (1998). In addition, secondary service connection may also be found in certain instances when a service-connected disability aggravates another condition. See Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310(b). Thus, service connection may be established either by showing (1) direct service incurrence or aggravation, (2) an etiological relationship between the claimed condition and a service-connected disability, or (3) using applicable presumptions, if available. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). 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. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C. § 7104 (a); Baldwin v. West, 13 Vet. App. 1 (1999); see 38 C.F.R. § 3.303 (a). A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When considering whether lay evidence is competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, supra. The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show. The Veteran should not assume that the Board has overlooked pieces of evidence that are not specifically discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The law requires only that the Board provide reasons for rejecting evidence favorable to the Veteran. III. Service Connection for Athlete's Foot The Veteran seeks service connection for tinea pedis, claimed as bilateral athlete's foot, which he contends had its onset during service and that he has continued to experience symptoms since separation. He was afforded a VA examination in December 2014, where the Veteran stated that he first sought treatment for his feet in June 1973 at Fort Jackson and was told he had athlete's foot. He further stated that this was a chronic problem. Following physical evaluation, the VA examiner found a current diagnosis of tinea pedis. Ultimately, however, the examiner concluded that the Veteran's claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by his service. In support of this determination, the examiner stated that there was no mention of a foot related skin condition in the Veteran's STRs or on the separation exam. Further, the examiner also found no evidence of treatment for a skin condition in his current records. The Board finds the December 2014 VA medical opinion inadequate for several reasons. First, the examiner's negative nexus opinion was based on a lack of STRs showing treatment for a skin condition of the feet. However, the lack of evidence cannot be treated as substantive negative evidence. In other words, reliance on the lack of medical evidence, especially without consideration of lay statements, is an inadequate rationale. The Court has held that the mere absence of evidence does not equate to unfavorable evidence. See Forshey v. Principi, 284 F.3d 1335, 1358 (Fed. Cir. 2002) (en banc) (cautioning that negative evidence, meaning actual evidence weighing against a party, must not be equated with the absence of substantive evidence); see also Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that an examination must consider lay evidence of in-service incurrence or continuity of symptomatology since service). In fact, while the examiner relied on a lack of supporting service medical records, an STR dated April 19, 1977 clearly: (1) shows the Veteran's sought treatment for a foot skin condition in service; (2) notes a diagnosis of tinea pedis; and, (3) documents a similar problem incurring in 1973. Further, post-service medical records show he has had current treatment for this condition. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). The Board notes that VA identified the inadequacy of the examiner's opinion, prior to returning the claim to the Board, and requested an addendum opinion reconciling the aforementioned discrepancies. An opinion was provided in March 2016; however the examiner again came to a conclusion based on an inaccurate finding of a lack of evidence in the Veteran's service medical records. However, the examiner did note that the Veteran was treated for pseudo folliculitis barbae and issued a shave profile in 1976. As a result, the Board also finds the March 2016 addendum opinion to be inadequate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). During the pendency of this appeal, the Veteran has consistently asserted that he experienced recurrent foot fungus during his active military service, which has continued since his separation from service. Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology. Savage v. Gober, 10 Vet. App. 488, 496 (1997). In this case, the Veteran's assertions that he has continuously experienced foot fungus since his service are considered competent evidence. See Layno, 6 Vet. App. at 469-70. In light of the foregoing, the evidence supporting the claim is, at the very least, as probative (meaning as competent and credible) as the evidence against the claim. Consequently, the Board is of the opinion that the point of equipoise has been reached in this appeal. While the December 2014 VA examiner provided an inadequate medical opinion against a finding of service connection, there is no probative evidence that refutes the Veteran's statements or weighs against his claim. Therefore, these statements, when viewed in relation to the Veteran's in-service treatment for, and diagnosis of, tinea pedis, are entitled to significant probative weight, and thus, are sufficient to establish the presence of bilateral athlete's foot (tinea pedis) and a likely continuity of symptomatology from service to the present. 38 C.F.R. § 3.303(b). Undoubtedly, further medical inquiry can be undertaken with a view towards further developing this claim. However, in this regard, the Court has cautioned VA against seeking an additional medical opinion where favorable evidence in the record is unrefuted (or, at worst, evenly balanced for and against the claim) and indicated that it would not be permissible to undertake further development in this circumstance if the sole purpose was to obtain evidence against an appellant's claim. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003). But see also Douglas v. Shinseki, 23 Vet. App. 19 (2009) (distinguishing Mariano and contrarily holding that VA may undertake the development of additional evidence if it is necessary to render an informed decision on the claim). Accordingly, resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for bilateral athlete's foot are met. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). IV. Service Connection for Left Knee Disability The Veteran contends that his current left knee disability is etiologically related to a left knee strain he was treated for during service. Having carefully considered this claim, in light of the evidence of record and the applicable law, the Board concludes that the most probative evidence is against the Veteran's service connection claim. The Board will begin by addressing direct service connection. As noted above, the first element of direct service connection requires medical evidence of a current disability. In this case, the Veteran has a current diagnosis of bilateral knee osteoarthritis. See December 2014 VA Examination. Therefore, the Veteran has satisfied the first element of service connection. As previously mentioned, the second element of direct service connection requires medical evidence, or in certain circumstances, lay testimony, of an in-service incurrence or aggravation of an injury or disease. Initially, although arthritis is considered to be a "chronic disease" under 38 C.F.R. § 3.309(a), to be presumed to have been incurred during service, such chronic disease must manifest to a compensable degree within one year of separation from active duty. In this case, the first mention of a left knee condition in the medical evidence of record is a July 2010 treatment record indicating the Veteran reported left knee pain, which is well beyond the permissible presumptive period. Similarly, diagnostic testing in July 2010 revealed mild osteoarthritic changes in the left knee, which is likewise well beyond the permissible presumptive period. Therefore, service connection on a presumptive basis, for left knee arthritis, is not warranted. See Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed. Cir. 2013). An STR dated February 14, 1977 reflects the Veteran reported he had sprained his knee three days prior and, consequently, was requesting a profile from physical training for a few days. After physical evaluation, medical personnel indicated that range of motion of the left knee was good and documented the Veteran's complaint of his knee hurting only when he runs. The record indicates that he declined an x-ray. He was treated conservatively with an ace wrap, a heating pad, and a profile from running for one week. This is the only complaint of symptoms related to a left knee condition that is documented in the Veteran's STRs. Moreover, the Veteran's separation examination was normal and the corresponding report of medical history reflects that he denied having had, or presently having, any knee problems. In fact, the earliest post-service medical records demonstrating that the Veteran complained of, or was treated for, a left knee condition was in 2010, which is many years after his separation from active duty. See July 2010 VA Medical Record (indicating that Veteran reported left knee pain; and, finding a diagnosis of left knee arthritis). This prolonged period without complaints or treatment is evidence that there has not been a continuity of symptomatology, and it weighs against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (holding that VA did not err in denying service connection when the veteran failed to provide evidence which demonstrated continuity of symptomatology, and failed to account for the lengthy time period for which there is no clinical documentation of his low back condition). Nevertheless, during the pendency of this appeal, the Veteran has asserted that he experienced left knee symptoms during his active military service, which have continued since his separation from service. Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology. Savage v. Gober, 10 Vet. App. 488, 496 (1997). In this case, the Veteran's assertions that he has continuously experienced pain in his left knee since his service are considered competent evidence. Layno, 6 Vet. App. at 469-70. However, after weighing the Veteran's assertions of continuity against the absence of in-service treatment records detailing a chronic disability, his explicit denial of knee problems during the separation examination and on the report of medical history, and the prolonged period before the first documented post-service treatment and diagnosis, the Board finds that service connection for a left knee disability is not warranted on the basis of a continuity of symptomatology since active service. 38 C.F.R. § 3.303 (b). Even though presumptive service connection is not warranted, the Veteran is not precluded from establishing service connection for a diagnosed disability with proof of direct causation. See Combee v. Brown, 34 F.3d 1039, 1043-44 (Fed. Cir. 1994). Regarding direct incurrence, as noted above, a February 1977 STR shows the Veteran received treatment for his left knee. However, there is no other mention of any complaints of, or treatment for, a left knee condition within the remaining STRs. Following the Veteran's separation, the earliest documented evidence of any complaints or treatment for any left knee condition was over 30 years after his separation from service. The fact that a chronic condition was not shown for such a prolonged period after his period of active service weighs against a claim that it was related to service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (explaining that the Board may consider "evidence of a prolonged period without medical complaint," along with other factors in resolving a claim). The Veteran was afforded a VA examination in December 2014. Although the examiner documented the Veteran's reported medical history and identified his current diagnosis of bilateral knee arthritis, the examiner did not provide a medical opinion addressing the relationship, if any, between the Veteran's current left knee disability and his service. Accordingly, the AOJ requested an addendum opinion, which was provided in March 2016. Following review of the pertinent medical evidence and prior examination report, the examiner concluded that it is less likely as not that the Veteran's current left knee disability was caused by or a progression of the condition he was treated for during service. In support of this determination, the examiner indicated that there is a lack of chronological evidence of a left knee condition linked to service. Specifically, the examiner addressed the lack of any evidence in the Veteran's service treatment records documenting any additional treatment for the left knee strain sustained in 1977, as well as the lack of medical evidence or documentation of treatment in the intervening years until 2010. The examiner stated that, while the Veteran's reported lay-observable knee symptoms were considered, there is no clinical evidence of an onset of a chronic left knee condition at any point during his active military service. The Board finds that the December 2014 VA examination was thorough and adequate and provided a sound basis upon which to base a decision with regard to the Veteran's service connection claim. See Barr v. Nicholson, 21 Vet. App 303, 311 (2007). Additionally, the March 2016 VA medical opinion is highly probative, as it was prepared by a medical professional who reviewed the Veteran's pertinent medical history, conducted an in-person evaluation, and clearly assessed the nature of his left knee condition. Moreover, the examiner's opinions are based on reliable principles and are supported by other evidence of record. See Neives-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that most of the probative value of an opinion comes from the discussion of its underlying reasoning or rationale). Based on the foregoing, the Board finds that the preponderance of the evidence is against a finding that the Veteran's current left knee disability is etiologically related to his active military service, to include the left knee strain he was treated for during service. Although he has maintained that his current condition is related to service, the most probative evidence indicates otherwise. The Board recognizes that the Veteran is competent to report symptoms that he perceives through his own senses, but these reports must be weighed against the medical evidence of record. See Layno v. Brown, 6 Vet. App. at 469. While the Veteran has attempted to establish a nexus through his own lay assertions, he is not competent to offer an opinion as to the etiology of his left knee condition due to the medical complexity of the matter involved. Again, the Board notes that arthritis requires specialized training for a determination as to diagnosis and causation and, consequently, falls outside the realm of common knowledge of a layperson susceptible to lay opinions on etiology. Consequently, the Veteran is not competent to render a nexus opinion or attempt to present lay assertions to establish a nexus between his current diagnosis and his active service. See Jandreau v. Nicholson, 492 F.3d at 1377 n.4. As the preponderance of the evidence is against a finding that the Veteran's current left knee disability is etiologically related to his active military service, the benefit of the doubt rule is not applicable here. See 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). V. Service Connection for PTSD There are particular requirements for establishing service connection for PTSD in 38 C.F.R. § 3.304(f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Entitlement to service connection for PTSD requires: medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f) and 38 C.F.R. § 4.125 (requiring PTSD diagnoses to conform to the DSM-V). If the evidence establishes that a veteran engaged in combat with the enemy and the claimed stressor is related to that combat, in the absence of clear and convincing evidence to the contrary, and provided that the claimed stressor is consistent with the circumstances, conditions, or hardships of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(1); see 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d) (pertaining to combat veterans). A finding that the veteran engaged in combat with the enemy, however, requires that the veteran participated in events constituting an actual fight or encounter with a military foe or hostile unit or instrumentality, and does not apply to veterans who served in a general "combat area" or "combat zone" but did not themselves engage in combat with the enemy. See VAOPGCPREC 12-99 (October 18, 1999). Prior to a recent amendment to the regulations, where a determination was made that a veteran did not "engage in combat with the enemy," or the claimed stressor was not related to combat, the veteran's lay testimony alone was insufficient to establish the occurrence of the alleged stressor. See Moreau v. Brown, 9 Vet. App. 389, 395 (1996). In such cases, service records or other corroborative evidence were required to substantiate or verify the veteran's testimony or statements as to the occurrence of the claimed stressor. See West (Carlton) v. Brown, 7 Vet. App. 70, 76 (1994). Effective July 13, 2010, however, 38 C.F.R. § 3.304(f) was amended to reduce the evidentiary burden of establishing a stressor when it is related to a fear of hostile military or terrorist activity. See 75 Fed. Reg. 39843-01 (July 13, 2010), codified at 38 C.F.R. § 3.304(f)(3). The amendment provides that, if a stressor claimed by a veteran is related to the veteran's fear of hostile military activity, and a VA psychiatrist or psychologist confirms that the claimed stressor is adequate to support a diagnosis of PTSD, then a veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor, as long as the claimed stressor is consistent with the places, types, and circumstances of the veteran's service and there is no clear and convincing evidence to the contrary. Id. "Fear of hostile military activity" is defined to mean that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. Id. The list of examples of such an event or circumstance specifically includes attack upon friendly military aircraft, vehicle-imbedded explosive devices, and incoming artillery, rocket, or mortar fire. Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits. VA shall consider all information and lay and medical evidence of record and when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt goes to the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). At the outset, the Board notes that the Veteran had periods of active military service during a period of war. However, the Veteran's personnel records indicate that he did not have service in Vietnam or combat service. The evidence does not suggest that he engaged in combat with the enemy. Thus, neither the combat provisions of 38 U.S.C. § 1154 nor the rule relating to combat stressors are applicable. The Veteran contends that he has PTSD that is related to his service. In a June 2010 Statement in Support of Claim for Service Connection for PTSD, the Veteran described a single in-service stressor. He asserted that, while stationed at Darmstadt in Germany, he witnessed a soldier jump from the third floor of the barracks and land about four or five feet in front of him. He indicated that the noise and blood from the impact scared him. He stated that he did not know the name of the soldier. Here, as reflected in an August 2009 VA treatment record, a VA psychiatrist has diagnosed the Veteran with PTSD, chronic, late onset (exploding after events of 2005, to include events that happened during his military service in Germany). Assuming, without conceding, that the Veteran's diagnosis of PTSD is adequate, there is, however, a need to corroborate the claimed in-service stressor. A stressor involves exposure to a traumatic event in which the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others and the person's response involved intense fear, helplessness, or horror. See Cohen v. Brown, 10 Vet. App. 128 (1997). The evidence necessary to establish the occurrence of an in-service stressor varies depending on whether or not the veteran engaged in combat with the enemy. Gaines v. West, 11 Vet. App. 353, 358 (1998). If it is determined through military citation or other supportive evidence that a veteran engaged in combat with the enemy, and the claimed stressor is related to combat, the veteran's lay testimony, alone, is sufficient to verify the claimed in-service stressor. 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d), (f). Here, VA was unable to verify the Veteran's claimed in-service stressor after numerous attempts. In December 2015, VA summarized the efforts that were taken to corroborate the claimed incident where a soldier jumped out of a third floor window in Darmstadt Germany in 1976 or 1977. However, the appropriate agencies were unable to verify this stressor. If a stressor claimed by a veteran is related to the veteran's fear of hostile military activity, and a VA psychiatrist confirms that the claimed stressor is adequate to support a diagnosis of PTSD, a veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor, as long as the claimed stressor is consistent with the places, types, and circumstances of the veteran's service and there is no clear and convincing evidence to the contrary. 38 C.F.R. § 3.304(f)(3). "Fear of hostile military activity" is defined to mean that a veteran experienced, witnessed, or was confronted with an event or circumstance that involved actual or threatened death or serious injury, or a threat to the physical integrity of the veteran or others, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. The list of examples of such an event or circumstance specifically includes attack upon friendly military aircraft, vehicle-imbedded explosive devices, and incoming artillery, rocket, or mortar fire. See 38 C.F.R. § 3.304(f)(3). The Board finds that the relaxed standard based on fear of hostile military activity does not apply in the instant case, because the claimed stressor is not based on a fear of hostile military activity. Instead, the Veteran's stressor relates to military activity by his own troops, which is not hostile military activity. If a claimed stressor is not related to combat or fear of hostile or military activity, a veteran's lay statements alone are not sufficient to establish the occurrence of the alleged stressor. Moreau v. Brown, 9 Vet. App. 389, 395-396 (1996); Dizoglio v. Brown, 9 Vet. App. 163, 166 (1996). Rather, the record must contain service records or other corroborative evidence substantiating the veteran's testimony or statements as to the occurrence of the claimed stressor. See West (Carlton) v. Brown, 7 Vet. App. 70, 76 (1994); Zarycki v. Brown, 6 Vet. App. 91, 98 (1993). In this case, the Veteran's accounts of what happened simply are not supported by any actual evidence of record. Specifically, no credible corroborating evidence has been able to be found in support of his contentions. As the Veteran's lay statements alone are not sufficient to verify his claimed stressor, the claim for PTSD must be denied. Moreau, 9 Vet. App. at 395-396; Dizoglio, 9 Vet. App. at 166. VI. Service Connection for Diabetes Mellitus and Prostate Cancer The Veteran's post-service treatment records confirm he has received the required diagnosis of diabetes mellitus, type II. Likewise, his medical records also establish a current diagnosis of prostate cancer. So there is competent medical evidence of these claimed disabilities. See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that service connection presupposes a current diagnosis of the condition claimed, to at least confirm the Veteran has it; without this minimum level of proof, there can be no valid claim). However, as already alluded to, there still must be competent and credible evidence also of a relationship between these disabilities and his military service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993); Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000); D'Amico v. West, .209 F.3d 122, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546,548 (2000); and Collaro v. West, 136 F.3d 1304, 1308 (Fed. Cir. 1998). The Veteran readily acknowledges that neither his diabetes mellitus, nor prostate cancer was diagnosed during his time in service or even within one year of his discharge, much less shown to be disabling to the minimally-required degree of at least 10-percent disabling, so it may not be presumed to have been incurred during his service, at least not under the provisions of 38 U.S.C. §§ 1101, 1112, 1113 and 38 C.F.R. §§ 3.307 and 3.309(a). Regarding diabetes, during the July 2014 Board hearing, the Veteran asserted that entitlement to service connection for diabetes was nevertheless warranted, instead, on the basis that it is presumptively associated with his exposure to herbicides-like the dioxin in Agent Orange-during his service. Even though he indicated that he did not have any foreign service in Vietnam, Thailand or Korea (where VA in certain instances has conceded Agent Orange was sprayed), he claimed that Agent Orange was used during his time at Fort Jackson. See February 2014 Board Hearing Transcript at 37-39. However, in a September 2014 statement, the Veteran clarified that he was not claiming that his diabetes was due to exposure to Agent Orange exposure, but, instead, was caused by his claimed exposure to radiation during service. Therefore, further consideration of whether any of his claimed disabilities, specifically including diabetes, are the consequence of herbicide exposure is not required inasmuch as he, himself, acknowledges there was no such exposure. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a), 3.309(e). The Board notes that, in December 2015, VA issued a formal finding regarding the inability to corroborate the Veteran's allegation of herbicide exposure at Fort Jackson. As the Veteran served in radio communications during service, the duties of which might have exposed him to electromagnetic fields, the Veteran was afforded a VA compensation examination in December 2014 to address the relationship, if any, between his diabetes mellitus and prostate cancer and his claimed exposure to electromagnetic fields. Following review of the evidence of record, including the Veteran's lay statements and internet articles discussing possible risks with such exposure, the examiner concluded that the Veteran's diabetes was less likely than not etiologically related to service. In support of this determination, the examiner indicated that neither PTSD, nor an exposure to electromagnetic fields is a risk for diabetes mellitus. The examiner stated that diabetes mellitus, type II, is caused by a pancreatic dysfunction and is not influenced by either of the Veteran's contentions. Additionally, the examiner similarly concluded that the Veteran's prostate cancer was less likely than not etiologically related to service. In support of this determination, the examiner cited medical treatise evidence from the World Health Organization indicating that exposure to electromagnetic fields is not a risk factor for prostate cancer. The examiner also indicated that the Veteran's STRs contain no indication or evidence suggesting an onset of prostate cancer during active duty. The Board finds that the December 2014 VA examination was thorough and adequate and provided a sound basis upon which to base a decision with regard to the Veteran's service connection claims. See Barr v. Nicholson, 21 Vet. App 303, 311 (2007). Additionally, the consequent medical opinions are highly probative, as they was prepared by a medical professional who reviewed the Veteran's pertinent medical history, conducted an in-person evaluation, and clearly assessed the nature of his diabetes mellitus and prostate cancer. Moreover, the examiner's opinions are based on reliable principles and are supported by other evidence of record, including medical treatise documentation. These opinions, therefore, are entitled to a lot of probative weight. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). This is especially true in comparison to the Veteran's lay assertions to the contrary, particularly since neither type II diabetes mellitus nor prostate cancer are a simple condition, rather, complex, including as concerning its origins and even the notion that it was aggravated during or on account of the Veteran' service. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (indicating lay evidence must demonstrate some competence and affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation). For these reasons, the Board finds that the preponderance of the evidence is against both claims of entitlement to service connection for type II diabetes mellitus and prostate cancer. The Veteran was eventually diagnosed with these conditions over 20 years after his separation from service, and, although this fact, alone, is not reason enough to deny his claims, there also has not been the required attribution of these conditions to his service. 38 C.F.R. § 3.303(d). See also Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Mense v. Derwinski, 1 Vet. App. 354 (1991) (holding that VA did not err in denying service connection when the Veteran had failed to provide evidence demonstrating continuity of symptomatology and had failed to account for the lengthy time period following his service during which there was no clinical documentation of the claimed disorder). Ultimately, the Board must consider all the evidence relevant to the claim, including the availability of medical records, the nature and course of the disease or disability, the amount of time that has elapsed since military service, and any other pertinent facts. Cf. Dambach v. Gober, 223 F.3d 1376, 1380-81 (Fed. Cir. 2000). Therefore, when appropriate, the Board may consider the absence of evidence when engaging in a fact-finding role. See Jordan v. Principi, 17 Vet. App. 261 (2003) (Steinberg, J., writing separately) (noting that the absence of evidence may be considered as one factor in rebutting the aggravation part of the section 1111 presumption of soundness). All said, neither diabetes mellitus nor prostate cancer has been attributed to his active military service by a competent and credible medical opinion or by evidence of a continuity of symptomatology. The Veteran is competent to report symptoms that he perceives through his own senses, but these reports must be weighed against the medical evidence of record. See Layno v. Brown, 6 Vet. App. at 469. While he has attempted to establish the required nexus through his personal lay assertions, he is not competent to offer an opinion on the etiology of his diabetes or prostate cancer because, as stated, of its medical complexity. Determining the origins of these types of conditions require specialized training for determinations as to diagnosis and causation and, thus, fall outside the realm of common knowledge of a layperson susceptible to lay opinions on etiology. Accordingly, he is not competent to render a nexus opinion or attempt to present lay assertions to establish a nexus between his current diagnoses and his active service. See Jandreau, supra. As the preponderance of the evidence is against finding that either the Veteran's type II diabetes mellitus or prostate cancer is etiologically related to his active military service, the benefit-of-the-doubt rule is inapplicable. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). VII. Secondary Service Connection Claims As noted above, service connection may also be granted on a secondary basis for a condition that is not directly caused by the Veteran's service, if it is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310. For these claims, establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either proximately caused by or proximately aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310(b). In this case, the Veteran is seeking service connection for right knee and low back disabilities, which he contends are both attributable to his current left knee condition. The Veteran has not asserted, nor does the record reflect that either his right knee or low back disabilities first manifested during service or are related to his service. See, e.g. January 2016 VA examination report (documenting Veteran's reported onset of back pain in 1980s and right knee pain in 2007). It has only been claimed that these disabilities are secondary to his left knee condition. Accordingly, since the Veteran does not contend that these disabilities are directly related to service and because the record similarly does not reasonably raise the theory of direct service connection, the Board will address only whether the Veteran is entitled to service connection for these disabilities on a secondary basis. See Robinson v. Mansfield, 21 Vet. App. 545, 552-56 (2008) (concluding "that the Board is not required sua sponte to raise and reject 'all possible' theories of entitlement in order to render a valid opinion" and "commits error only in failing to discuss a theory of entitlement that was raised either by the appellant or by the evidence of record"), aff'd sub nom. Robinson v. Shinseki, 557 F.3d 1355 (Fed.Cir.2009) (stating that "[w]here a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory"). The findings set forth earlier in this decision reflect that the Veteran was not entitled to service connection for a left knee disability. As service connection has not been established in this case, there is no factual or legal basis upon which to award service connection for a disability that is claimed as secondary to a disability that is not service connected. See 38 C.F.R. § 3.310. In reaching this conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the claims, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). ORDER Resolving all reasonable doubt in the Veteran's favor, entitlement to service connection for bilateral athlete's foot (tinea pedis) is granted. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a right knee disability, including as secondary to the left knee disability is denied. Entitlement to service connection for a low back disability, including as secondary to the left knee disability is denied. Entitlement to service connection for PTSD is denied. Entitlement to service connection for diabetes mellitus type II is denied. Entitlement to service connection for prostate cancer is denied. ____________________________________________ Keith W. Allen Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs