Citation Nr: 18160737 Decision Date: 12/27/18 Archive Date: 12/27/18 DOCKET NO. 11-16 361 DATE: December 27, 2018 ORDER The claim of entitlement to service connection for plantar warts of the left foot is granted. The claim of entitlement to service connection for an acquired psychiatric disability, to include anxiety neurosis and posttraumatic stress disorder (PTSD), is denied. REMANDED The claim of entitlement to service connection for hammertoes of the right foot, claimed as secondary to service-connected bony exostosis, is remanded. The claim of entitlement to service connection for hammertoes of the left foot, claimed as secondary to service-connected bony exostosis, is remanded. The claim of entitlement to a disability rating greater than 10 percent for a bony exostosis of the talus area of the left foot is remanded. The claim of entitlement to a disability rating higher than 10 percent for a bony exostosis of the talus area of the right foot is remanded. FINDINGS OF FACT 1. Competent, probative evidence, including a VA examiner opinion, indicates that the Veteran has a recurrent plantar wart that began during service as a result of a viral infection. 2. It is established by clear and unmistakable evidence that the Veteran’s anxiety disorder pre-existed his active duty service. 3. It is established by clear and unmistakable evidence that the Veteran’s pre-existing anxiety disorder was not aggravated beyond the natural progression of the disorder during or as a result of service. 4. The Veteran does not have a current PTSD diagnosis. 5. Although the Veteran has asserted that he has psychiatric disability that was incurred during service, there is no competent, probable evidence of record indicating that he suffered from or was diagnosed with psychiatric during service or within the one-year period following his separation from service, or that a psychiatric disability was otherwise the result of his active service. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran’s favor, the criteria for service connection plantar warts of the left foot are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for an acquired psychiatric disability, to include anxiety neurosis and PTSD, are not met. 38 U.S.C. §§ 1101, 1111, 1112, 1113, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1970 to February 1972. This appeal to the Board of Veterans Appeals (Board) arose from May 2009, September 2009, and November 2011 rating decisions. In the May 2009 rating decision, the Department of Veterans Affairs (VA) Regional Office (RO), inter alia, denied ratings greater than 10 percent for the service-connected bony exostosis of the left and right feet, and denied service connection for hammertoes of both feet and plantar warts of the left foot. The Veteran perfected an appeal to the Board with respect to these claims with submission of a VA Form 9 in May 2011, following issuance of a statement of the case (SOC) that same month. The Board notes parenthetically that, although the Veteran has previously appealed the initial ratings assigned following the award of service connection for the bony exostosis of the feet, as addressed in December 2004 and October 2005 rating decisions, the Veteran contacted the RO in November 2008 in order to request that the appeal be withdrawn. Accordingly, although the Board previously characterized these claims in light of the distinction noted in Fenderson v. West, 12 Vet. App. 119, 126 (1999) (distinguishing initial rating claims from claims for increased ratings for already service-connected disability), as the Veteran’s prior appeal as to these issues was withdrawn and he subsequently initiated new claims for higher ratings, the Board now considers these claims as standard claims for higher ratings. While the Veteran contacted the RO in September 2011, requesting that his claim for service connection for hammertoes be withdrawn, where he also presented testimony with respect to this claim during the July 2013 hearing, and private medical evidence supporting this claim was received in September 2013, the Board the previously determined that there had not actually been an effective withdrawal of the claim, thus the claim remained on appeal. At this juncture, the Board notes that where the schedule for rating disabilities provides that hammertoes of the feet are to be rated on a unilateral basis, the claims may be properly addressed as distinct claims with respect to each foot. See 38 C.F.R. § 4.71a, Diagnostic Code 5282. In a September 2009 rating decision, the RO denied service connection for depression. In June 2010, the Veteran contacted the RO requesting to open a claim for “service connected stress related to depression.” Clarification received from the Veteran in a July 2010 telephone conversation with the RO was to the affect that the Veteran desired to file a claim for service connection for PTSD and, in essence, did not wish to pursue a claim for service connection for depression. Following a November 2011 rating decision denying the claim for service connection for PTSD, the Veteran ultimately perfected an appeal to the Board with respect to the claim for service connection for PTSD with submission of a VA Form 9 in April 2013 following issuance of a March 2013 SOC addressing this claim. In July 2013, the Veteran testified during a hearing before the undersigned Veterans Law Judge at the RO; a transcript of the hearing is of record. The Board previously remanded the claims on appeal to the agency of original jurisdiction (AOJ) for further evidentiary development in November 2014 and April 2017. As previously noted by the Board, the RO appropriately characterized the psychiatric disability claim denied in November 2011 as one for service connection for PTSD, a distinct psychiatric disability for which service connection was not previously denied, as opposed to the psychiatric disability claim previously denied in an October 2005 rating decision. See Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008); see also Ephraim v. Brown, 82 F.3d 399 (Fed. Cir. 1996). Further, the Board acknowledges that the Veteran has only perfected an appeal with respect to the denial of service connection for PTSD. In November 2014, the Board explained that, given the evidence of record that appears to overlap the Veteran’s prior and current psychiatric claims; the fact that such evidence provided a favorable basis for reopening the previously-denied claim; and to accord the Veteran full due process, the appeal as to psychiatric disability was characterized as encompassing the separate matters of whether new and material evidence had been received to reopen a claim for service connection for acquired psychiatric disability other than PTSD (previously characterized as anxiety neurosis) and entitlement to service connection for acquired psychiatric disability (to include anxiety neurosis and PTSD). Combining the reopened claim for psychiatric disability other than PTSD with the de novo claim for service connection for PTSD gave the Veteran every consideration in connection with his efforts to establish service connection for psychiatric disability. Cf. Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that, in determining the scope of a claim, the Board must consider the claimant’s description of the claim, the symptoms described and the information submitted or developed in support of the claim). In the November 2014 decision and remand, the Board granted the Veteran’s petition to reopen the claim for service connection for an acquired psychiatric disability other than PTSD. The underlying claim for service connection for a psychiatric disability, as well as the other service connection and higher rating issues on appeal, were all remanded to the AOJ for further development. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. See 38 U.S.C. § 1131, 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in or aggravated by service. See 38 C.F.R. § 3.303(d). Generally, to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Each determination as to whether the elements of a claim are met is based on an analysis of all the evidence of record and evaluation of its competency, credibility and probative value. See Buchanan v. Nicholson, 451 F.3d 1331(Fed. Cir. 2006) Baldwin v. West, 13 Vet. App. 1, 8 (1999). Certain chronic diseases, including psychoses manifest within one year of separation from service, shall be presumed to have been incurred in service if manifested to a compensable degree within the prescribed post-service period, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as 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 attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). In adjudicating a claim for VA benefits, 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(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). 1. Plantar Warts of the Left Foot The Veteran asserts that he developed a plantar wart during service, and that although the wart was removed, it has continued to recur ever few weeks since that time. As for the in-service injury or disease requirement for the claimed plantar wart, the Veteran’s service treatment records (STRs) document that the Veteran sought treatment for a plantar wart in January 1972. Initial treatment with an acid patch apparently did not resolve the problem. A subsequent report notes that the wart was removed and a dressing was applied. As for the matter of a current disability, the Veteran has continually asserted that he has experienced multiple recurrences of the wart, requiring cutting and/or removal of the wart periodically. A March 2004 VA clinical report noted that the Veteran had recurring plantar warts which he would “cut out” himself on a monthly basis. Another March 2004 VA clinical report noted that the Veteran had a painful plantar wart on the ball of his foot. More recently, March 2009 and November 2010 VA podiatry treatment reports note that the Veteran had a painful callus on the bottom of his left foot. Continuing reports note the Veteran’s ongoing reports of calluses which he appeared to believe to be associated with the wart. During recent VA examination of his feet in August 2017, the examiner noted that although it was difficult to examiner his foot, he had a plantar wart by history and that that was his likely diagnosis during the examination. Thus, affording the Veteran the benefit of the doubt, the Board finds that the current disability requirement for service connection for the plantar wart has been met, as the wart has likely been present during the appeal period. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. With respect to the question of whether there exists a medical nexus between the current disability and the Veteran’s noted plantar wart during service, in the report of a January 2016 VA examination, the examiner gave the opinion that, although there was no wart present on the examination, it was likely that the Veteran had a wart removed while in service and that he had had recurrences of at least one plantar wart due to the presence of a virus since that time. In providing the opinion, the examiner explained that plantar warts were caused by a virus. While the examiner additionally opined that it was not at least as likely as not that the Veteran’s plantar wart was caused or aggravated by his service-connected exostoses of the feet, where the examiner provided a favorable opinion with a respect to direct relationship between the Veteran’s recurring plantar wart and the plantar wart diagnosed and treated during service, the opinion as to any secondary relationship affords no additional probative value to the question of in-service incurrence of the disability. The Board finds the January 2016 VA examiner’s opinion to be of significant probative value. The examiner had reviewed the Veteran’s STRs and post-service treatment records, and considered the Veteran’s reports. Based on the evidence, the examiner concluded that the Veteran had likely had recurring occurrences of plantar wart due to virus that was first present during his active service. Cf. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). To the extent that the opinion relies on the Veteran’s lay reports, the Board emphasizes that VA is not free to ignore a medical opinion or pertinent medical findings (see Owens v. Brown, 7 Vet. App. 429, 433 (1995)), or to reject such a medical opinion based on its own medical judgment (see Obert v. Brown, 5 Vet. App. 30 (1993) and Colvin v. Derwinski, 1 Vet. App. 171 (1991)), even if the opinion is based, in part, on lay assertions. In the instant case, the Board has determined that the Veteran’s reports are credible, and the examiner, although rejecting that the disability was present during the examination, noted that the Veteran had had plantar wart recurrence since the first manifestation during service. Thus, based on the foregoing, the Board finds that the evidence of record is, at least, relatively evenly balanced on the medical nexus question. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. See 38 C.F.R. § 3.102; see also 38 U.S.C. § 5107; Gilbert, 1 Vet. App. at 53-56. Given the facts noted above, and resolving any reasonable doubt on certain elements of the claim in the Veteran’s favor, the Board concludes that the criteria for service connection for a plantar wart of the left foot are met. 2. Acquired Psychiatric Disability The Veteran’s essential assertion with respect to his claimed psychiatric disability is that he developed psychiatric symptoms during his active service. He asserted that he has been chronically depressed and anxious since his Naval service during the Vietnam Era. More recently, he has asserted that he developed PTSD as a result of building bombs while serving in the Navy. He reported on other occasions that two of the bombs that he had built exploded in the water about 50 yards away from his location. Review of the Veteran’s STRs reveals that in December 1970, the Veteran sought treatment with a report of feeling chills and dizziness for about one week. In addressing the Veteran’s report of dizziness and his history of vestibular vertigo, the report additionally noted symptoms including tension headaches and nervous tension. Later, in April 1971, the Veteran was referred for a psychiatric consultation after being accused of openly committing a lewd act in the berthing compartment. The Veteran denied the accusation, but admitted to committing a “suggestive gesture” in a “joking spirit.” The report noted that his life within the unit had become intolerable. The report further noted that he lacked the emotional maturity to cope with the situation. Thus, he was referred for an assessment of his emotional and psychological development. The report of an assessment, conducted two days later, indicated that per the Veteran’s report, his actions did not suggest any perversion or anything other than normal male joking. The report further noted that the Veteran demonstrated a certain emotional liability which made his future in his unit tenuous under current circumstances. The physician conducting the evaluation determined, however, that the Veteran did not demonstrate psychosis and that he would probably do well on active duty. The physician also noted that while the Veteran’s mood was one of moderate depression, his affective range was normal. The impression upon conclusion of the report was that the Veteran did not have a psychiatric disorder. There is no further indication of complaints of treatment for psychiatric symptoms in the Veteran’s STRs. Thus, although the record indicates that the Veteran was emotionally immature, and at one point had nervous tension, possibly associate with other illness, the Veteran’s STRs do not indicate that he was diagnosed with psychiatric disability during service. Turning to the current disability requirement, the Board notes that the record supports a finding that the Veteran has current diagnoses of generalized anxiety disorder (anxiety neurosis) and bipolar disorder, as noted in various VA psychiatric treatment report, including in March 2009 and June 2013. With respect to the Veteran’s claimed PTSD, the Board finds that the record does not support the Veteran’s contention that he has a current PTSD diagnosis. Nonetheless, due to the evidence pertaining to the diagnosis and/or etiology of each of these psychiatric disabilities, the Board will address each disability in turn. A. Anxiety Disorder In addition to the basic legal authority governing service connection cited above, pertinent to the etiology of the Veteran’s current anxiety disorder, the Board further notes that every person employed in the active military, naval, or air service shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. To rebut the presumption of soundness in 38 U.S.C. § 1111, VA must show, by clear and unmistakable evidence, (1) that the disease or injury existed prior to service, and (2) that the disease or injury was not aggravated by service. VAOPGCPREC 3-2003 (July 16, 2003). The claimant is not required to show that the disease or injury increased in severity during service before VA’s duty under the second prong of this rebuttal standard attaches. Id. See also Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). The term “clear and unmistakable evidence” signifies evidence that cannot be misunderstood or misinterpreted; it is that which is undebatable. Vanerson v. West, 12 Vet. App. 254 (1999). In determining whether there is clear and unmistakable evidence to rebut the presumption of soundness, all evidence of record must be considered, including post service medical opinions. Harris v. West, 203 F.3d 1347 (Fed. Cir. 2000); Adams v. West, 13 Vet. App. 453 (2000). The term “noted” denotes only such disorders that are recorded in examination reports. The existence of disorders prior to the active military service reported by a veteran as medical history do not constitute a notation of such disorders, but it will be considered together with all of the other evidence in question as to the commencement of the disease or disorder. 38 C.F.R. § 3.304(b)(1). Determinations of whether a disorder pre-existed the active military service should be based on a thorough analysis of the evidentiary showing and careful correlation of all medical facts, with due regard to manifestations, clinical course and character of the particular injury or disease or residuals thereof. Id. An injury or disease that has been determined to be pre-existing will be presumed to have been aggravated by service where there is an increase in the severity of the disability during service. The burden to show no aggravation of a pre-existing disease or disorder during service lies with the government. Cotant v. Principi, 17 Vet. App. 117, 131 (2003). “Temporary or intermittent flare-ups during service of a preexisting injury or disease are not sufficient to be considered ‘aggravation in service’ unless the underlying condition, as contrasted to symptoms, is worsened.” See Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). Here, the Board finds competent medical evidence of record clearly and undebatably establishes that the Veteran’s anxiety disorder pre-existed service, and that the disorder was not aggravated beyond natural progression during or as a result of service. Although the disability was not specifically noted on the Veteran’s April 1970 enlistment examination report, based on review of the claims file, various medical treatment records, and the Veteran’s statements, a VA psychologist conducted a VA examination of the Veteran in January 2013, and provided additional opinions as to the etiology of the Veteran’s anxiety in December 2015 and August 2017 reports. In these reports, the psychologist concluded that the Veteran’s anxiety disorder clearly and unmistakably pre-existed his military service. Specifically, in the January 2013 report, the psychologist noted that the medical evidence established that the Veteran suffered from anxiety and nervous facial tics since childhood. The Veteran had reported that he has always been nervous, but he denied having any mental health treatment prior to service. In all reports, the psychologist noted that the Veteran also was noted to have done poorly in school, failing first and sixth grades, and that he was expelled in ninth grade for having knocked out a male history teacher. Thus, the examiner concluded that the Veteran’s anxiety disorder clearly and unmistakably pre-existed his military service. Significantly, there is no contrary medical evidence or opinion on this point. Review of psychiatric treatment records dated following the Veteran’s separation from service reveals that he was admitted to private psychiatric facility for approximately one month beginning in December 1979. The Veteran had suffered a psychotic episode at that time which was noted to be due to the sudden death of his maternal grandfather, which resulted in his family being quite shocked and upset. The report noted that shortly before his admission, in November 1979, he was found slumped in the front seat of his father’s car. He had been drinking heavily the previous night. The report noted that the Veteran had recently become increasingly demanding, nervous, and high strung at home. He had also become progressively helpless and regressive, not eating at times, not bathing, and claiming that he could not understand the television. The report noted further that the Veteran had long-standing problem of being anxious, demanding and rather immature. A June 1980 private therapist treatment report confirmed that the Veteran’s immediate symptoms in November 1979 developed after the death of his grandfather. In the August 2017 addendum opinion the VA examiner also opined that the Veteran’s pre-existing anxiety disorder clearly and unmistakably was not aggravated or permanently worsened beyond its natural progression during or as a result of the Veteran’s active service. Here, the examiner noted that the Veteran had one sick call in 1970 where he was noted as being tense, and that there was no ongoing mental health treatment or mental health diagnosis during service. Moreover, during his evaluation in April 1971, he was found to not have a psychiatric disorder. The examiner reasoned that if the Veteran’s anxiety disorder has increased in severity during service, it would be expected that there would be evidence of mental health symptoms or treatment in the years shortly following his separation from service. Here, there was no evidence of mental health problems or treatment from the time of the Veteran’s discharge until 1979, when he sought treatment following at a private facility, at which time he was noted to have been frequently using PCP and alcohol. The examiner noted that PCP use would explain his psychosis and regression with activities of daily living in November 1979. Moreover, the examiner noted that the precipitant to the Veteran’s mental health symptoms was the polysubstance abuse and the death of his grandfather. Later, his first VA treatment was in 2004 and was noted to be related to his father’s terminal illness and cocaine use. Significantly, there is also no contrary medical evidence or opinion on this point. The Board finds the January 2013, December 2015, and August 2017 opinions of the VA psychologist, collectively, to be of significant probative value. The psychologist based her conclusions on examination of the Veteran, and consideration of his history, assertions, and pertinent medical literature, and such conclusions were supported by stated rationale. Thus, the Board accepts these conclusions as probative evidence on the questions of pre-existence and in-service aggravation upon which this claim, as relating to claimed anxiety disorder, turns. See, e.g, Nieves-Rodriguez, 22 Vet. App. at 301; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). A. Bipolar Disorder As to the etiology of the Veteran’s bipolar disorder, the Board notes that a March 2004 letter from a treating VA psychologist and VA psychiatrist indicated that the Veteran was severely ill in terms of his mental health. The clinicians noted the Veteran’s presentation of symptoms and his impairment in daily functioning. The clinicians indicated in the letter that a diagnosis of bipolar disorder appeared to most adequately explain his presentation and symptoms. While the clinicians advocated for the award of disability benefits for the Veteran, they did not provide any clear etiology opinion linking the Veteran’s bipolar disorder to his active service. As previously noted, bipolar disorder has also been diagnosed during the appeal period. In the August 2017 VA opinion, the VA psychologist again pointed out that the Veteran’s early mental health records note that his current mental health symptoms began after the death of his maternal grandfather in November 1979. She further noted that he first sought mental health treatment at a VA clinic in March 2004, at which time he was first diagnosed with bipolar disorder, after suffering longterm severe anxiety, aggravated by failures to find employment and the pending death of his terminally ill father. The examiner opined that the Veteran’s current bipolar disorder did not have its onset during service, was not manifested within one-year after his separation from service, and was not otherwise related to his claimed stressor of making bombs during service. Rather, the examiner opined that the Veteran’s bipolar disorder was related to his history of polysubstance abuse, and the multiple deaths in his family from 1979 to 2013, including his parents upon whom he was very dependent. The Board finds the VA psychologist’s August 2017 opinion as to the etiology of the Veteran’s bipolar disorder to also be fully informed, fully articulated, and well-reasoned; and, thus, probative, See Nieves-Rodriguez, 22 Vet. App. at 301 (2008). The psychologist fully described the Veteran’s treatment history and onset of his bipolar disorder and noted a clear etiology leading to the onset of the bipolar disorder. The psychologist clearly described why the Veteran’s bipolar disorder was not at least as likely as not incurred during or as a result of the Veteran’s active service, and provided an alternate etiology for the disability. Based on the thorough opinion, the Board cannot find that service connection is warranted for the Veteran’s bipolar disorder. B. PTSD With respect to the Veteran’s claimed PTSD, the Board notes that while the record contains multiple reports indicating that he had symptoms indicative of PTSD, a diagnosis of PTSD is not officially noted in the record, to include during the current appeal period. The first evidence of indication of possible PTSD is noted in a July 2003 psychiatric evaluation conducted in pursuit of the Veteran’s claim for disability benefits administered by the Social Security Administration. The report noted that the Veteran had felt chronically severely depressed and anxious since serving in Vietnam in 1972, and had occasional flashbacks of combat experience. The report further noted that he had been hospitalized on two occasions, the first in 1979, as previously referenced. While the psychiatrist conducting the evaluation concluded that the Veteran had probable, untreated PTSD, the conclusion appears to be based, at least in part, on the Veteran’s misreported assertion of being involved in combat. In this regard, the Board notes that service personnel records associated with the claims file do not reflect that he was involved in combat, and the Veteran himself confirmed in an April 2012 statement, and during the January 2013 VA examination that he did not see combat during his service. In any regard, the July 2013 evaluation did not clearly diagnose PTSD. A March 2004 VA clinical evaluation also noted a diagnosis of rule out PTSD. Notably, however, a PTSD diagnosis was not made and the reasons for the potential diagnosis were not clearly stated. Additionally, the Veteran’s treating VA psychiatrist provided a statement in support of his claim in November 2012. The psychiatrist noted the Veteran’s treatment history for severe anxiety disorder and bipolar disorder. She noted the Veteran’s history of working on bombs and his report of seeing two bombs explode, and of having episodes of frequent thoughts of his frightening experiences over the years. She further provided a report of his psychiatric symptoms and indicated that it appeared that he was experiencing some PTSD-like symptoms, though, she noted, he had not been formally diagnosed. In an effort to determine the nature and etiology of any present PTSD, the Veteran was afforded a VA PTSD examination in September 2011. After examining the Veteran, the psychologist conducting the examination concluded that the Veteran did not meet the required diagnostic criteria for PTSD. The examiner noted that the Veteran worked as an ordnance mechanic during his Naval service. During the examination, however, the Veteran did not report his bomb making experience as a stressor, but rather indicated that exposure to radiation as a result of working on a nuclear submarine was his claimed stressor. The examiner concluded that the Veteran had not been exposed to a traumatic event, and that he did not reexperience any traumatic event. Thus, the examiner concluded that the Veteran did not have a PTSD diagnosis. During subsequent the January 2013 VA mental disorders examination, the VA psychologist also concluded, upon examination of the Veteran, that there was no evidence of PTSD or other major mental health disorder during the examination. The psychologist incidentally noted that the Veteran had lost several family members, including his maternal grandfather in 1979, his brother in 1999, his mother in 2002, and his father in 2004, and suffered an increase in anxiety after these losses, especially after the deaths of his parents. While the Veteran has asserted that he suffers from PTSD or “stress” as a result of his in-service experiences, there is no clear evidence of record establishing a PTSD diagnosis. Given the lack of evidence of current PTSD, service connection cannot be awarded for the disability. See 38 U.S.C. § 1131; Caluza v. Brown, 7 Vet. App. 498, 506 (1995) (holding that service connection cannot be awarded in the absence of competent evidence of current disability); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (stating that “Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability”). Furthermore, with respect to all present and claimed psychiatric disabilities, to whatever extent the Veteran and/or his representative attempt to assert that the Veteran has current PTSD or that his anxiety disorder or bipolar disorder was incurred in or aggravated by his service, such assertions do not provide persuasive support for the claim. Matters of diagnosis and etiology of medical disabilities typically are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). Although lay persons are competent to provide opinions on some simple medical issues (see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011)), the specific matter of the etiology of the disability under consideration is a complex medical matter that falls outside the realm of common knowledge of a lay person; cf. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007) (holding that lay persons are not competent to diagnose cancer). As neither the Veteran nor his representative is shown to be other than a layperson without appropriate medical training and expertise, neither is competent to render a probative (persuasive) opinion on any medical matter upon which this claim turns. See, e.g., Bostain v. West, 11 Vet. App. 124, 127 (1998). Hence, the lay assertions in this regard have no probative value. Overall, then, there is no competent, probative evidence of record to establish that the Veteran suffers from current PTSD or that his anxiety disorder or bipolar disorder were at least as likely as not incurred during or as a result of service, or aggravated by his active service. Rather, the weight of the competent, probative evidence on these points is adverse to the claim. For all of the foregoing reasons, the Board finds that the claim for service connection for an acquired psychiatric disorder must be denied. In reaching the conclusion to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). REASONS FOR REMAND Unfortunately, the Board finds that further AOJ action on the remaining claims on appeal is warranted, even though such will, regrettably, further delay an appellate decision on these matters. A remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Pursuant to the Board’s May 2017 remand, the Veteran was afforded a VA examination of his feet in August 2017. The examination findings, however, were not entirely responsive to the remand directives. In this regard, the Board specifically directed that the VA examiner provide an opinion with respect to whether diagnosed hammertoes of the feet is at least as likely as not was caused by or has been aggravated by service-connected bilateral bony exostoses of the feet. The Board also asked for a complete, clearly stated rationale for all conclusions reached. Similar to the VA examiner’s opinion provided in the January 2016 VA examination report, which necessitated the remand for a new VA examination, in opining that the Veteran’s hammertoes were less likely than not caused by or aggravated by his service-connected bilateral bony exostoses of the feet, the August 2017 VA examiner merely concluded that hammertoes were not diagnosed during service. The examiner provided no reasons or discussion as to why the Veteran’s hammertoes were not caused or aggravated by the service-connected bony exostoses of the feet. See Nieves-Rodriguez, 22 Vet. App. at 301 (a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two). Additionally, the Board notes that findings in the August 2017 VA examination report with respect to the Veteran’s service-connected bilateral exostoses of the feet are not entirely clear. In this regard, the Board notes that the medical evidence shows that the Veteran suffers from multiple disabilities of his feet, and the evidence does not clearly indicate which disabilities are manifestations of his service-connected bony exostoses as opposed to manifestations of separate, non-service connected disabilities. Notably, the August 2017 VA examination report indicated that the Veteran had pain on passive range of motion testing, and when his foot joint is used in non-weight bearing, thereby possibly indicating joint involvement of the exostoses disabilities. Additionally, the examiner described the Veteran as having hallux valgus of the feet. Moreover, in describing the severity of the Veteran’s foot disabilities the examiner indicated that the Veteran had mild foot disability, however, it is unclear whether this was only referring to the described plantar wart which was also described. In this regard, a prior, March 2011, VA examination report indicated that the Veteran’s foot condition was significantly disabling, however, it was unclear whether other, non-service connected disabilities were also considered in the description. Based on these deficiencies, the Board finds that an additional examination for the bony exostoses of the feet is necessary in order for a VA examiner to provide a clear description of the overall severity of foot disability due only to the Veteran’s service-connected bilateral exostoses. 38 C.F.R. § 4.2. Prior to undertaking action responsive to the above, to ensure that all due process requirements are met and that the record is complete, the AOJ should undertake appropriate action to obtain and associate with the claims file all outstanding, pertinent records. As for VA records, the claims file currently includes VA outpatient treatment records dated through March 2017. Accordingly, the AOJ should obtain all outstanding records of VA evaluation and/or treatment of the Veteran dated since March 2017. The AOJ should also give the Veteran another opportunity to provide additional information and/or evidence pertinent to the claims on appeal (particularly, regarding private (non-VA) treatment), explaining that he has a full one-year period for response. See 38 U.S.C. § 5103(b)(1); but see also 38 U.S.C. § 5103(b)(3) (clarifying that VA may decide a claim before the expiration of the one-year notice period). Thereafter, the AOJ should attempt to obtain any additional evidence for which the Veteran provides sufficient information and, if necessary, authorization, following the procedures prescribed in 38 C.F.R. § 3.159. The actions identified herein are consistent with the duties imposed by the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, identification of specific actions requested on remand does not relieve the AOJ of the responsibility to ensure full compliance with the VCAA and its implementing regulations. Hence, in addition to the actions requested above, the AOJ should also undertake any other development and/or notification action deemed warranted by the VCAA prior to adjudicating the claims on appeal. Adjudication of the higher ratings claims should include consideration of the provisions of 38 C.F.R. § 3.321, as well as whether any staged rating—assignment of different ratings for distinct periods of time, based on the facts found—is appropriate. These matters are hereby REMANDED for the following action: 1. Obtain complete copies of all outstanding records of VA evaluation and/or treatment of the Veteran, dated since March 2017. Follow the procedures set forth in 38 C.F.R. § 3.159(c) regarding requesting records from Federal facilities. All records and/or responses received should be associated with the claims file. 2. Send to the Veteran and his representative a letter requesting that the Veteran provide sufficient information concerning, and, if necessary, authorization to enable VA to obtain, any additional evidence pertinent to any claim(s) on appeal that is not currently of record. Specifically request that the Veteran furnish, or furnish appropriate authorization to obtain, all outstanding, pertinent private (non-VA) records. Clearly explain to the Veteran that he has a full one-year period to respond (although VA may decide the claims within the one-year period). 3. If the Veteran responds, assist him in obtaining any additional evidence identified, following the current procedures set forth in 38 C.F.R. § 3.159. All records/responses received should be associated with the claims file. If any records sought are not obtained, notify the Veteran of the records that were not obtained, explain the efforts taken to obtain them, and describe further action to be taken. 4. After all records and/or responses received are associated with the claims file, arrange for the Veteran to undergo a new VA examination of his feet, by an appropriate physician. The contents of the entire, electronic claims file, to include a complete copy of this REMAND, must be made available to the designated individual, and the examination report should reflect consideration of the Veteran’s documented medical history and assertions. All indicated tests and studies should be accomplished (with all findings made available to the examiner prior to the completion of his or her report), and all clinical findings should be reported in detail. Bilateral Bony Exostoses: Considering both the examination results and the Veteran’s documented history and assertions, the examiner should clearly identify all manifestations, to include hallux valgus and joint involvement, of the bilateral bony exostoses of the feet. The examiner should also indicate whether, due to the bony exostoses, there is limitation of foot motion or objective evidence of pain on motion, weakness, excess fatigability, and/or incoordination. The examiner should additionally describe the frequency, duration, characteristics, severity, and functional loss during any flare-ups and with repeated use due to bony exostoses disability of either foot. If the examination is not conducted during a flare-up, based on examination results and the Veteran’s documented history and assertions, the physician should indicate whether, and to what extent, the Veteran experiences likely functional loss due to pain and/or any of the other symptoms noted above during flare-ups and/or with repeated use over time. The examiner should discuss the overall severity of foot disability of each foot due only to bony exostoses, describing whether the disabilities result in moderate, moderately severe, or severe foot impairment of each foot. Hammertoes: The examiner should render an opinion, consistent with sound medical judgment, as to whether it is at least as likely as not (i.e., a 50 percent or greater probability), that the disability: (a) had its onset in service or is otherwise medically-related to service; or, if not, (b) was caused, OR is or has been aggravated (worsened beyond the natural progression) by service-connected bony exostoses and/or recurring left foot plantar wart. If aggravation is found, the examiner should attempt to quantify the extent of additional disability resulting from aggravation, to include by identifying (to the extent possible), the baseline level of disability prior to aggravation. In addressing the above, the examiner should comment on the Veteran’s reports of having hammertoes present during service. The examiner is advised that the Veteran is competent to report symptoms, and any lay assertions in this regard must be considered in formulating the requested opinions. If lay assertions in any regard are discounted, the examiner should clearly so state, and explain why. All examination findings/testing results, along with complete, clearly-stated rationale for the conclusions reached, must be provided. 5. To help avoid future remand, ensure that all requested actions have been accomplished (to the extent possible) in compliance with this REMAND. If any action is not undertaken, or is taken in a deficient manner, appropriate corrective action should be undertaken. See Stegall, 11 Vet. App. at 271. 6. After completing the requested actions, and any additional notification and/or development deemed warranted, adjudicate the remaining claims on appeal considering all pertinent evidence (to include all evidence added to the electronic claims file since the last adjudication) and legal authority (to include, for each higher rating claim, consideration of whether any staged rating of the disability is appropriate). JACQUELINE E. MONROE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Michael Wilson, Counsel