Citation Nr: 1804308 Decision Date: 01/23/18 Archive Date: 01/31/18 DOCKET NO. 14-07 140 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for an acquired psychiatric disorder. 2. Entitlement to service connection for hemorrhoids. 3. Entitlement to service connection for a bilateral foot disorder. 4. Entitlement to service connection for a right knee disorder. 5. Entitlement to a temporary total rating based upon convalescence following right knee surgery. REPRESENTATION Appellant represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL The Veteran (Appellant) ATTORNEY FOR THE BOARD E. Blowers, Counsel INTRODUCTION The Veteran, who is the appellant, had active service from June 1978 to August 1978, and from June 1979 to February 1985. In a December 1991 administrative decision, VA determined that basic eligibility exists on the conditional period of service from June 28, 1979 to June 27, 1983. The discharge for the period of service from June 28, 1983 to February 6, 1985 was determined to be under dishonorable conditions. This matter came before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating. The case was first before the Board in July 2015, where the Board remanded the issues on appeal to obtain outstanding VA treatment records, to ask the Veteran to provide any available service treatment records, and to schedule the Veteran for a hearing before the Board. In a subsequent May 2016 decision, the Board again remanded the issues on appeal to obtain outstanding Social Security Administration (SSA) records and to schedule the Veteran for relevant VA examinations. A remand by the Board confers on the claimant, as a matter of law, the right to compliance with the remand orders. Failure of the Board to ensure compliance with remand instructions constitutes error and warrants the vacating of a subsequent Board decision. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Having reviewed the record, the Board finds that its July 2015 and May 2016 remand directives were adequately complied with on remand; therefore, the Board finds the issues on appeal are ripe for adjudication. The Veteran testified from Atlanta, Georgia, at a September 2015 Board videoconference hearing before the undersigned Veterans Law Judge, who was seated in Washington, D.C. The hearing transcript has been associated with the record. The instant matter is a Veterans Benefits Management System (VBMS) appeal. The Board has reviewed both the VBMS and the "Virtual VA" files so as to insure a total review of the evidence. The issue of a temporary total rating based upon convalescence following right knee surgery is 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 is currently diagnosed with multiple acquired psychiatric disorders, to include posttraumatic stress disorder (PTSD) and depressive disorder. 2. The currently diagnosed acquired psychiatric disorders are due to multiple post-service stressors. 3. The Veteran is currently diagnosed with hemorrhoids. 4. During service the Veteran had rectal bleeding after consuming C-rations. 5. The currently diagnosed hemorrhoids are not related the consumption of C-rations during service. 6. The Veteran is currently diagnosed with the bilateral foot disorders of flat foot (pes planus) and plantar fasciitis. 7. The currently diagnosed pes planus is a congenital defect and was not subject to a superimposed disease or injury during service. 8. The currently diagnosed plantar fasciitis is a result of the non-service-connected pes planus. 9. The Veteran is currently diagnosed with arthritis of the right knee. 10. During service the Veteran fell and injured the right knee. 11. The Veteran experienced "continuous" symptoms of arthritis of the right knee since service separation. CONCLUSIONS OF LAW 1. The criteria for service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.326, 4.125 (2017). 2. The criteria for service connection for hemorrhoids have not been met. 38 U.S.C. §§ 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.326(a) (2017). 3. The criteria for service connection for a bilateral foot disorder have not been met. 38 U.S.C. §§ 1111, 1131, 1153, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.306, 3.326(a), 4.9 (2017). 4. Resolving reasonable doubt in the Veteran's favor, the criteria for presumptive service connection for arthritis of the right knee have been met. 38 U.S.C. §§ 1101, 1131, 1133, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.326(a) (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and to Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.326(a). 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. § 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. As the instant decision grants service connection for a right knee disorder of arthritis and remands the issue of a temporary total rating based upon convalescence following right knee surgery, the Board need not discuss the duties to notify and assist as to those issues. In April 2012, VA issued a VCAA notice, which informed of the evidence generally needed to support a claim for service connection, what actions needed to be undertaken, and how VA would assist in developing the claim. The notice was issued to the Veteran prior to the June 2012 rating decision from which this appeal arises. Further, the issues on appeal were readjudicated in a February 2014 Statement of the Case (SOC), and a subsequently issued June 2017 Supplemental Statement of the Case (SSOC); therefore, there was no defect with respect to the timing of the VCAA notice. See Pelegrini v. Principi, 18 Vet. App. 112 (2004). Regarding the duty to assist in this case, the Veteran was afforded VA foot, hemorrhoid, and mental health examinations during the course of this appeal. The examination reports are of record. Further, VA has also received a copy of a report concerning a February 2013 SSA mental health examination. To that end, when VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The examination reports reflect that, taken together, the VA and private examiners reviewed the record, conducted in-person examinations with appropriate testing, and adequately answered all relevant questions. In September 2009, VA issued a Formal Finding on the Unavailability of Service Records. Specifically, VA found that the Veterans service treatment records are missing and unavailable. When service records are unavailable through no fault of a veteran, VA has a heightened duty to assist, to explain its findings and conclusions, and to carefully consider the benefit-of-the-doubt rule. Washington v. Nicholson, 19 Vet. App. 362, 369-70 (2005); Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). All relevant documentation, including SSA records and VA and private treatment (medical) records, has been secured or attempted to be secured to the extent possible, and all relevant facts have been developed. There remains no question as to the substantial completeness of the record as to the service connection issues on appeal. 38 U.S.C. §§ 5103, 5103A, 5107; 38 C.F.R §§ 3.102, 3.159, 3.326(a). Any duties imposed on VA, including the duties to assist and to provide notification, have been met as set forth above. Service Connection Law and Regulation Service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 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). Arthritis is a chronic disease under 38 C.F.R. § 3.309(a). As such, 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 the issue on appeal. Walker, 708 F.3d 1331. The Veteran's currently diagnosed hemorrhoid and mental health disorders are not chronic diseases under 38 C.F.R. § 3.309(a), and the presumptive service connection provisions under 38 C.F.R. § 3.303(b) do not apply. Id. Under 38 C.F.R. § 3.303(b), service connection will be presumed where there are either chronic symptoms shown in service or continuity of symptomatology since service for diseases identified as "chronic" in 38 C.F.R. § 3.309(a). Walker, 708 F.3d at 1338-40 (holding that continuity of symptomatology is an evidentiary tool to aid in the evaluation of whether a chronic disease existed in service or an applicable presumptive period). With a chronic disease shown 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. 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. 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). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a) (2012); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (addressing lay evidence as potentially competent to support presence of disability even where not corroborated by contemporaneous medical evidence). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The Board has thoroughly reviewed all the evidence in the Veteran's claims file and adequately addresses the relevant evidence in the instant decision. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, every piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). Service Connection for an Acquired Psychiatric Disorder 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. If the evidence establishes a diagnosis of PTSD during service and the claimed stressor is related to that service, 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. If the evidence establishes that the 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. If a stressor claimed by a veteran is related to the veteran's fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. "Fear of hostile military or terrorist activity" means 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, such as from an actual or potential improvised explosive device; vehicle-imbedded explosive device; incoming artillery, rocket, or mortar fire; grenade; small arms fire, including suspected sniper fire; or attack upon friendly military aircraft, and the veteran's response to the event or circumstance involved a psychological or psycho-physiological state of fear, helplessness, or horror. 38 C.F.R. § 3.304(f). If a veteran did not engage in combat with the enemy, or the claimed stressors are not related to combat, and the stressor is not related to "fear of hostile military or terrorist activity," then the veteran's testimony alone is not sufficient to establish the occurrence of the claimed stressors and his testimony must be corroborated by credible supporting evidence. Cohen v. Brown, 10 Vet. App. 128 (1997); Moreau v. Brown, 9 Vet. App. 389 (1996); Dizoglio v. Brown, 9 Vet. App. 163 (1996). Furthermore, service department records must support, and not contradict, the claimant's testimony regarding non-combat stressors. Doran v. Brown, 6 Vet. App. 283 (1994). The question of whether a veteran was exposed to a stressor in service is a factual one, and VA adjudicators are not bound to accept uncorroborated accounts of stressors or medical opinions based upon such accounts. Wood v. Derwinski, 1 Vet. App. 190 (1991), aff'd on reconsideration, 1 Vet. App. 406 (1991). Hence, whether a stressor was of sufficient gravity to cause or support a diagnosis of PTSD is a question of fact for medical professionals, and whether the evidence establishes the occurrence of stressors is a question of fact for adjudicators. In this case, the Veteran has advanced that PTSD developed as a result of various in-service stressors, to include witnessing the deaths of multiple service-members by suicide. Initially, the Board finds that the Veteran is currently diagnosed with multiple acquired psychiatric disorders, to include posttraumatic stress disorder (PTSD) and depressive disorder. Such diagnoses can be found in the reports from the February 2013 SSA mental health evaluation and the June 2016 VA mental health examination. Next, the Board notes that the Veteran's in-service stressors have not been confirmed. Throughout the course of this appeal, the Veteran has advanced seeing multiple service-members commit suicide during service, to include by gunshot wound to the head. Further, the Veteran also conveyed seeing one service member either jump from, or be pushed from, a great height, resulting in the service-member's death. In April 2017, VA issued a PTSD stressor verification review memorandum. Per the memorandum, the relevant record custodians were unable to locate records confirming the suicides advanced by the Veteran. There is no suggestion that these events involving other service members would be a part of this Veteran's service treatment records; therefore, the service treatment records would have no tendency to corroborate the reported in-service stressors. Moreover, even if the reported in-service stressors were confirmed, the preponderance of the evidence of record reflects that the currently diagnosed acquired psychiatric disorders, to include the PTSD, are due to multiple post-service stressors rather than to in-service events. As noted above, in February 2013, the Veteran received a SSA mental health examination. Per the examination report, the SSA examiner reviewed the Veteran's entire mental health history with the Veteran. Examination of the Veteran revealed the following stressors: the Veteran's first wife was caught in the crossfire of a gunfight between two drug dealers, resulting in her death, in 2004; the Veteran's second wife died of an aneurysm while sleeping next to the Veteran in 2011; the Veteran's father was electrocuted to death; and the Veteran's best friend from service also died. At the conclusion of the examination, the SSA examiner assessed that the aforementioned stressors resulted in the currently diagnosed acquired psychiatric disorders, to include PTSD and depressive disorder. The Board finds this opinion to be supported by the other evidence of record. The Board notes that there is some confusion as to when the Veteran's friend from service died. At the September 2015 Board hearing, the Veteran first testified that the friend/roommate committed suicide 14 or 15 years earlier, which would be after service. When it was pointed out to the Veteran that this time frame was post-service, the Veteran then testified that the friend committed suicide in 1982. At the February 2013 SSA examination, the Veteran referred to the friend as "my roommate throughout my service." Such a statement indicates that the Veteran was roommates with this friend until the end of service, and supports a finding that this friend did not commit suicide until after the Veteran separated from service. As such, the Board finds that the Veteran confused the friend's post-service suicide with the unconfirmed suicides the Veteran advanced witnessing during service. For this reason, the friend's post-service suicide may not be considered a service event for service connection purposes; to the contrary, this evidence shows a post-service stressful event that the Veteran has reported, and examiner has accepted, along with other post-service events, as sufficient to cause a psychiatric disorder first diagnosed after service. Finally, the Board notes that in June 2016 a VA examiner opined that the Veteran's currently diagnosed PTSD was related to "potential traumatic stressors" during service. Such a statement begs the question of whether there were actual stressful events in service. In April 2017, a second VA examiner also opined that the PTSD was at least as likely as not related to witnessing one or more suicides during service; however, the opinion report reflects that the opinion was based solely off the statement of the VA examiner in June 2016 regarding the occurrence of in-service stressors. Again, the Board notes that the reported in-service stressors have not been confirmed; however, even if said stressors were confirmed, the June 2016 and April 2017 opinions are of no probative value because they do not consider and/or address the full and accurate history, which includes the multiple post-service stressors (death of wives, electrocution of father, post-service suicide of close friend). See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that an opinion based upon an inaccurate factual premise has no probative value). The Board has given consideration to the Veteran's contention of having one or more mental disorders related to in-service stressors. While the Veteran is competent to offer lay statements regarding mental health symptoms at any time, here, as a lay person, under the facts of this case, the Veteran does not have the requisite medical training or credentials to be able to render a competent medical opinion concerning the etiology of the currently diagnosed mental health disorders. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) cautions that the "proper use of these criteria requires specialized clinical training that provides both a body of knowledge and clinical skills." The "purpose of DSM-IV is to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose" various mental disorders. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) cautions that it was "not sufficient to simply check off the symptoms in the diagnostic criteria to make a mental disorder diagnosis." Rather, clinical training is required "to recognize when the combination of predisposing, precipitating, perpetuating, and protective factors has resulted in a psychopathological condition in which physical signs and symptoms exceed normal ranges." The "purpose of DSM-5 is to assist trained clinicians in the diagnosis" of various mental disorders. See Young v. McDonald, 766 F.3d 1348, 1353 (Fed. Cir. 2014) (holding that "PTSD is not the type of medical condition that lay evidence . . . is competent and sufficient to identify"); Clemons v. Shinseki, 23 Vet. App. 1, 4-5 (2009) (holding that a claimant without medical expertise cannot be expected to precisely delineate the diagnosis of his mental illness); see also Waters v. Shinseki, 601 F.3d 1274, 1277 1278 (Fed. Cir. 2010) (concluding that a veteran's lay belief that his schizophrenia and anti-psychotic drugs to treat it had aggravated his diabetes and hypertension was not of sufficient weight to trigger VA's duty to seek a medical opinion on the issue). For these reasons, the Board finds that the weight of the evidence demonstrates that the Veteran's currently diagnosed acquired psychiatric disorders are not related to service. None of the Veteran's claimed in-service stressors has been verified or confirmed. Even if the evidence showed that the Veteran witnessed or heard about one or more suicides during service, the preponderance of the evidence reflects that the currently diagnosed acquired psychiatric disorders are due to multiple post-service stressors (death of wives, electrocution of father, post-service suicide of close friend). As above, the Board has given consideration to the Veteran's contention that one or more mental health disorders are related to service; however, the Veteran is a lay person and, while competent to discuss mental health symptoms, does not have the requisite medical training or credentials to be able to render a competent opinion as to etiology. Because the preponderance of the evidence is against service connection for an acquired psychiatric disorder, to include PTSD and depressive disorder, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Service Connection for Hemorrhoids The Veteran asserts that currently diagnosed hemorrhoids are related to the in-service consumption of C-rations and related rectal bleeding. Initially, the Board finds that, per the June 2016 VA rectal examination, the Veteran is currently diagnosed with hemorrhoids. The Board finds that during service the Veteran had rectal bleeding after consuming C-rations. Specifically, at the September 2015 Board videoconference hearing, the Veteran testified that during service most service-members who consumed C-rations had rectal bleeding. The Board notes that the Veteran has not contended, and the record does not reflect, any other in-service injury, disease, or event that may have resulted in the currently diagnosed hemorrhoids. After a review of all the lay and medical evidence of record, the Board finds that the weight of the evidence is against a finding that the Veteran's consumption of C-rations during service caused the currently diagnosed hemorrhoids. As noted above, the Veteran received a VA rectal examination in June 2016. At the conclusion of the examination, the VA examiner opined that it was less likely than not that the currently diagnosed hemorrhoids were related to the consumption of C-rations during service. The VA examiner explained that, after a review of the medical literature, no peer reviewed studies (or any credible research) supported the Veteran's assertion that C-ration consumption could result in hemorrhoids. The Board finds this opinion to be supported by and consistent with the other evidence of record. The Board has given consideration to the Veteran's contention that the reported in-service rectal bleeding was due to hemorrhoids caused by C-ration consumption. While the Veteran is competent to offer lay statements regarding the observable symptom of rectal bleeding at any time, here, as a lay person, under the facts of this case, the Veteran does not have the requisite medical training or credentials to be able to render a competent medical opinion concerning whether the in-service rectal bleeding was due to hemorrhoids, and whether said hemorrhoids were due to C-ration consumption. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (recognizing that lay competency is determined on a case by case basis); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (holding that rheumatic fever is not a condition capable of lay diagnosis). For these reasons, the Board finds that the weight of the evidence demonstrates that the Veteran's currently diagnosed hemorrhoids are not related to service. A VA examiner, after reviewing the medical literature, has opined that consumption of C-rations does not result in hemorrhoids. No other in-service injury, disease, or event that may have caused the hemorrhoids have been advanced by the Veteran or shown by the evidence of record. As above, the Board has given consideration to the Veteran's contention that C-ration consumption may have caused the hemorrhoids; however, the Veteran is a lay person and, while competent to discuss rectal bleeding symptoms, does not have the requisite medical training or credentials to be able to render a competent opinion as to hemorrhoid etiology. Because the preponderance of the evidence is against service connection for hemorrhoids, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Service Connection for a Bilateral Foot Disorder The Veteran asserts that a currently diagnosed bilateral foot disorder is related to the wearing of black boots during service. Initially, the Board finds that, per a June 2016 VA foot examination, the Veteran is currently diagnosed with the bilateral foot disorders of flat foot (pes planus) and plantar fasciitis. Pes planus is a congenital defect. Congenital or developmental "defects" are considered to have preexisted service. 38 C.F.R. § 3.303(c), 4.9. Service connection is generally precluded by regulation for such "defects" because they are not "diseases" or "injuries" within the meaning of applicable legislation. 38 C.F.R. § 3.303 (c), 4.9, 4.127 (2017); accord Terry v. Principi, 340 F.3d 1378, 1383-84 (Fed. Cir. 2003); Palczewski v. Nicholson, 21 Vet. App. 174, 179 (2007). To establish service connection for a congenital defect, the evidence must show superimposed disease or injury during service. VAOPGCPREC 82-90. Defects are defined as "structural or inherent abnormalities or conditions which are more or less stationary in nature." VAOPGCPREC 82-90. A defect differs from a disease in that a defect is "more or less stationary in nature," while a disease is "capable of improving or deteriorating." See VAOPGCPREC 82-90 at para. 2. The presumption of soundness does not apply to congenital defects because such defects "are not diseases or injuries" within the meaning of 38 U.S.C. § 1110 and 1111. See 38 C.F.R. § 3.303(c); Terry, 340 F.3d at 1385-86 (holding that the presumption of soundness does not apply to congenital defects); Winn v. Brown, 8 Vet. App. 510, 516 (1996) (holding that a non-disease or non-injury entity such as a congenital defect is "not the type of disease- or injury-related defect to which the presumption of soundness can apply"). The Veteran received a VA foot examination in June 2016. Per the examination report, the Veteran reported having bilateral foot and heel pain that was treated with over-the-counter Epsom salts. The Veteran denied ever being evaluated or treated by podiatry through VA. Review of the Veteran's VA treatment records supports this assertion. The Veteran advanced that the pain was constantly at a six out of ten on the pain scale, with occasional flare-ups of pain. Upon examination the pes planus showed no other symptoms beyond pain. At the conclusion of the examination, after reviewing all the relevant evidence of record, the VA examiner opined that the currently diagnosed pes planus was congenital in nature. The VA examiner noted that examination of the feet showed that neither foot had experienced foot damage. The Veteran's own admission, the only symptom of the bilateral pes planus over the past 30 or more years was constant foot pain, with occasional painful flare-ups, which had not required treatment at a VA medical facility. Such evidence supports a finding that the currently diagnosed pes planus has been "more or less stationary in nature", which, in turn, reflects that the Veteran's bilateral pes planus is a congenital defect as contemplated by VA law and regulation. See VAOPGCPREC 82-90 at para. 2. Based upon the foregoing, the Board concludes that the Veteran's pes planus is a congenital defect and is not, in and of itself, subject to service connection. 38 C.F.R. § 3.303 (c), 4.9. As such, the evidence must show that the congenital or developmental defect was subject to a superimposed disease or injury during service that resulted in an additional disability. VAOPGCPREC 82-90. At the September 2015 Board videoconference hearing, the Veteran testified that black boots worn during service had "messed up" the Veteran's feet. The Veteran did not testify to an actual foot injury that could potentially constitute a "superimposed injury" of the foot; rather, the testimony was that a pair of boots was uncomfortable and/or had negative effects upon use does not rise to the level of a "superimposed injury" as contemplated by VA law and regulation. Further, review of all the evidence of record shows no other potential superimposed disease or injury of either foot during service. The June 2016 VA foot opinion report further supports the finding that the Veteran's currently diagnosed pes planus was not subject to a superimposed injury during service. Specifically, the VA opinion report conveys that, upon examination, the VA examiner found that the Veteran's feet showed "no damage" that may have been related to service. In other words, the VA examiner found no evidence of a superimposed injury during service that resulted in an additional foot disability. As noted above, at the June 2016 VA foot examination, the Veteran was also diagnosed with bilateral foot plantar fasciitis. At the conclusion of the examination, the VA examiner opined that the currently diagnosed plantar fasciitis was a result of the non-service-connected pes planus. The evidence of record supports this finding, and no evidence to the contrary has been received. The Board has given consideration to the Veteran's contention that one or more bilateral foot disorders are related to service. While the Veteran is competent to offer lay statements regarding the observable symptom of foot pain at any time, here, as a lay person, under the facts of this case, the Veteran does not have the requisite medical training or credentials to be able to render a competent medical opinion concerning whether a currently diagnosed foot disorder is related to service. See Kahana, 24 Vet. App. at 438 (whether lay evidence is competent regarding a particular disability is determined on a case by case basis; holding that ACL injury is too "medically complex" for lay diagnosis); 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"); 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 the above reasons, and considering all the relevant lay and medical evidence, the Board finds that the Veteran's currently diagnosed pes planus is a congenital defect and was not subject to a superimposed disease or injury during service that resulted in additional disability. Further, the Board finds that the currently diagnosed plantar fasciitis was caused by the non-service-connected pes planus. Consequently, the Board finds that service connection for any bilateral foot disorder is not warranted. Because the preponderance of the evidence is against service connection for a bilateral foot disorder, the benefit of the doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Service Connection for a Right Knee Disorder The Veteran asserts that a currently diagnosed right knee disorder is related to an in-service fall. It has been the Veteran's contention that the right knee pain has continued from service separation to the present. Initially, the Board finds that the Veteran is currently diagnosed with arthritis of the right knee. The report from a June 2016 VA knee examination reflects that X-ray imaging showed arthritis in the right knee. Next, the Board finds that during service the Veteran fell and injured the right knee. At the September 2015 Board videoconference hearing, the Veteran credibly testified to slipping and falling on ice during physical training. The Veteran testified to injuring the right knee in the fall and receiving treatment for the injury. While the Veteran's service treatment records are missing, the Veteran's testimony is supported by a December 2012 lay statement from a fellow service member. Per the letter, the service member advanced witnessing the Veteran's injury to the right knee during service. Having reviewed all the evidence of record, lay and medical, the Board finds that the weight of the evidence is at least in equipoise on the question of whether the Veteran experienced "continuous" symptoms since service separation of arthritis of the right knee to meet the requirements for presumptive service connection for the chronic disease of arthritis. See 38 C.F.R. § 3.303(b). In December 1999, the Veteran filed a claim for service connection for a right knee disorder. Per the claim, the Veteran advanced injuring the right knee during service and receiving treatment for the right knee during service on multiple occasions from November 1981 to July 1983. Subsequently, in September 2008, the Veteran filed a new claim for service-connected for a right knee disorder. The Veteran again advanced receiving treatment for a right knee injury from approximately 1980 to 1983. Per October and November 2010 VA treatment records, the Veteran sought treatment for right knee pain that the Veteran stated had been present since 1980 and had worsened in the past few years. The Veteran conveyed having injured the right knee in 1980. Multiple subsequent VA treatment records reflect that the Veteran has continued to receive treatment for the right knee, and that the Veteran has consistently advanced injuring the right knee in service and having knee pain since that injury. At the September 2015 Board videoconference hearing, the Veteran credibly testified to having pain in the right knee since slipping falling on the ice during service. The Veteran also indicated having continuing knee pain since service at the June 2016 VA knee examination. At the conclusion of the June 2016 VA knee examination, the VA examiner opined that it was less likely than not that the currently diagnosed right knee disorder was related to service. This opinion appears to be based, at least in part, on the absence of available medical records detailing knee treatment prior to 2004. The VA examiner does not appear to have considered the Veteran's contention of symptoms of right knee pain since service separation. As such, the Board finds the negative nexus opinion is based on an incomplete and, therefore, inaccurate history, so is inadequate and of no probative value. See Reonal, 5 Vet. App. at 461 (holding that an opinion based upon an inaccurate factual premise has no probative value). The Veteran is currently diagnosed with arthritis of the right knee. During service the Veteran injured the right knee after slipping on ice during physical training. Throughout the course of this appeal, and well before, the Veteran has reported having right knee symptoms since the in-service injury, and the available medical evidence of record is consistent with the Veteran's lay statements. This evidence is sufficient to place in equipoise the question of whether the Veteran experienced continuity of symptomatology of a right knee disorder since service separation that was later diagnosed as arthritis of the right knee. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) (a veteran is competent to testify regarding continuous joint pain since service). Resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran injured the right knee in a fall during service and experienced "continuous" symptoms since service separation of arthritis of the right knee. As such, the criteria for presumptive service connection for arthritis of the right knee under 38 C.F.R. § 3.303(b) based on "continuous" post-service symptoms have been met. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As service connection is being granted on a presumptive basis based on continuous post-service symptoms under 38 C.F.R. § 3.303(b), there is no need to discuss entitlement to service connection on a direct or any other basis as other theories of service connection have been rendered moot, leaving no question of law or fact to decide. See 38 U.S.C. § 7104 (2012). Finally, the Board notes that the evidence of record indicates that the Veteran may be diagnosed with other right knee disorders, including residuals of right knee surgery. Where a veteran is diagnosed with multiple knee disorders, and it is unclear from the record which symptoms are attributable to each distinct disability, the Board is precluded from differentiating between the symptomatology and the disabilities. See Mittleider v. West, 11 Vet. App.181, 182 (1998) (per curiam). In this case, the Board is unable to differentiate the symptomatology of the now service-connected arthritis of the right knee from any other right knee disorders. As such, the Board has attributed all disability symptomatology and functional impairment to the now service-connected arthritis of the right knee, and the RO should consider all of the Veteran's right knee symptomatology and functional impairment when assigning an initial disability rating. For these reasons, the Board need not consider whether service connection is also warranted for any other right knee disorders. ORDER Service connection for an acquired psychiatric disorder is denied. Service connection for hemorrhoids is denied. Service connection for a bilateral foot disorder is denied. Service connection for arthritis of the right knee is granted. REMAND Temporary Total Rating for Right Knee Surgery The Veteran has sought a temporary total rating (38 C.F.R. § 4.30 (2017)) for reported periods of convalesce following one or more right knee surgeries during the relevant period on appeal. Previously, the temporary total rating was denied by the AOJ on the basis that the right knee was not service connected; however, in the instant decision the Board grants service connection for arthritis of the right knee. As such, the AOJ will subsequently be assigning initial disability ratings for the relevant periods on appeal, to include the periods in which the Veteran has reported convalescing from right knee surgery. As the AOJ will be assigning initial ratings from the date of service connection to the present, the question of a temporary total rating based upon convalescence following right knee surgery (38 C.F.R. § 4.30) is inextricably intertwined initial rating of the right knee arthritis when implementing the grant of service connection. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (the adjudication of claims that are inextricably intertwined is based upon the recognition that claims related to each other should not be subject to piecemeal decision-making or appellate litigation). Accordingly, the issue of a temporary total rating based upon convalescence following right knee surgery (38 C.F.R. § 4.30) is REMANDED for the following action: After assigning initial disability ratings for the now service-connected arthritis of the right knee for the initial rating period on appeal, readjudicate the issue of a temporary total rating based upon convalescence following right knee surgery (38 C.F.R. § 4.30). If any benefit sought on appeal remains denied, the Veteran and representative should be provided a SSOC. An appropriate period of time should be allowed for response before the case is returned to the Board. The Veteran has the right to submit additional evidence and argument on the 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 or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C. §§ 5109B, 7112 (2012). ______________________________________________ J. PARKER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs