Citation Nr: 1815139 Decision Date: 03/13/18 Archive Date: 03/19/18 DOCKET NO. 09-02 790 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for hypertension, to include as due to herbicide exposure or to a service connected disease or injury. 2. Entitlement to service connection for chronic obstructive pulmonary disease (COPD). 3. Entitlement to service connection for a headache disorder, to include as due to a service connected disease or injury. 4. Entitlement to service connection for a bilateral foot disability. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD P. Yoffe, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1971 to March 1975 in the U.S. Air Force as a Fuels Specialist. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2008 decision of the Regional Office (RO) of the Department of Veterans Affairs (VA) in Winston-Salem, North Carolina. The Board remanded the claims in September 2012, August 2016, and July 2017 and the claims return to the Board. The Board notes that the prior remands made findings regarding prior examinations of the relevant disabilities on appeal and requested new opinions. As a result, examinations prior to the July 2017 Board remand will not be discussed, except to the extent the new opinions referenced lay statements in the examinations or they contain relevant physical findings in prior examinations. FINDINGS OF FACT 1. Hypertension did not manifest in service, or within one year of separation, and is not otherwise attributable to service. 2. Hypertension disorder is unrelated (causation or aggravation) to a service-connected disease or injury. 2. COPD did not manifest in service and is not otherwise attributable to service. 3. Clear and unmistakable evidence demonstrates that a headache disorder pre-existed service and was not aggravated beyond its natural progression by service. 4. Headache disorder is not related (causation or aggravation) to a service-connected disease or injury. 5. Pes planus was noted at entry and did not increase in severity during service. 6. Other foot disability; to include bilateral hallux valgus, bilateral hallux rigidus, and bilateral degenerative arthritis, did not manifest in service, or within one year of separation, and is not otherwise attributable to service. CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated by service, and may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). 2. Hypertension is not proximately due to, the result of, or aggravated by service-connected disease or injury. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 3. COPD was not incurred in or aggravated by service. 38 U.S.C. §§ 1110 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 4. Headache disorder clearly and unmistakably preexisted service and was not aggravated therein, and the presumption of soundness at entrance is rebutted. 38 U.S.C. §§ 1110, 1111 (2012); 38 C.F.R. 3.303 (2017). 5. Headache disorder is not proximately due to, the result of, or aggravated by service-connected disease or injury. 38 U.S.C. § 1110 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). 6. Preexisting pes planus was not aggravated by service. 38 U.S.C. §§ 1110, 1111 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.306 (2017). 7. Other foot disability (bilateral hallux valgus, bilateral hallux rigidus, and bilateral degenerative arthritis) was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Compliance with Prior Remand In July 2017, the Board remanded the claims for a variety of addendum opinions on the multifaceted theories of entitlement and to obtain service treatment records from an in-service hospitalization around July 1972. The relevant opinions and records were obtained and are discussed below in the relevant sections. They comply with the Board's requests. These tasks having been accomplished, the Board's prior remand instructions have been substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Duties to Notify and Assist VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5103, 5103A, 5107, 5126 (2014); 38 C.F.R. §§ 3.159, 3.326 (2017). The Veteran and his representative have not raised any argument(s) with respect to the adequacy of notice and assistance. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Therefore, the appeal may be considered on the merits. Service Connection Service connection may be established for disability resulting from personal injury or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. § 1110 (2012). To establish a right to compensation for a present disability, a Veteran must show: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. 38 C.F.R. § 3.303(a); see also Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases; including hypertension and arthritis, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1113 (2012); 38 C.F.R. §§ 3.307, 3.309. With chronic disease shown as such in service 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 attributable to intercurrent causes. C.F.R. § 3.303(b). Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. Id. 38 C.F.R. § 3.303(b) applies only to chronic disease as listed in 38 U.S.C. § 1101(3) and 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Every veteran 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. The burden falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both pre-existing and not aggravated by service. Id. Clear and unmistakable evidence means evidence that "cannot be misinterpreted and misunderstood, i.e., it is undebatable." Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (quoting Vanerson v. West, 12 Vet. App. 254, 258-59 (1999)). A pre-existing injury or disease will be considered to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153. Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 C.F.R. § 3.306(b). In evaluating a claim, the Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1335 (2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (providing that 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 if (1) the medical issue is within the competence of a layperson, (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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007) (observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995). For a medical opinion (i.e., medical evidence) to be given weight, it must be: (1) based upon sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts. See Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). Hypertension The Veteran contends that he was diagnosed with hypertension (high blood pressure) in service with a blood pressure reading of 140/90 and in-service stress caused evaluated blood pressure and hypertension. See, e.g., Veteran's written correspondence received in October 2004 (noting also being placed on medication in service). The Veteran also contended that his hypertension is due to anxiety caused from PTSD. See January 2018 Informal Hearing Presentation (IHP). The Veteran noted he had a history of "high or low blood pressure" and "pain or pressure in chest" in his Report of Medical history upon induction in November 1970. Upon examination in November 1970, the Veteran was found to have normal heart and vascular systems and blood pressure was 114/64. As stated in the prior July 2017 Board remand, as no defect, infirmity, or disorder of the heart or vascular system was found during his entrance examination and there is no clear and unmistakable evidence of preexisting disability, the Veteran is presumed to have been sound at entrance. The Veteran reported pain in his chest in early July 1972. The Veteran was hospitalized in late July and August 1972 after returning from Vietnam with symptoms of fever, chest pain, nausea, and stomach pain diagnosed as suspected dengue fever. The Veteran's blood pressure readings were 140/80 and 168/80. He was discharged from the hospital in August 1972. At his August 1974 separation examination, the Veteran's vascular and heart system were evaluated as normal. Blood pressure was 110/72. The Veteran reported he made a full recovery from hospitalization in 1972. On his August 1974 Report of Medical History, he stated "no" for heart trouble or palpations or "high or low blood pressure." He did endorse pain or pressure in chest. The Veteran had additional in-service blood pressure ratings after the separation examination of 138/78 and 136/80 range in December 1974. The first report of hypertension was in a September 1999 VA treatment record, where the Veteran was reported to have untreated hypertension. This note reports that Veteran had taken medication in the past, but had stopped at some point. A notation on this record for "present medication" states "no meds x 13 years + stopped taking perself." The Board will interpret the September 1999 record as showing a 13 year history of hypertension in 1999, which would gave an onset date sometime around 1986. The Board remanded the claim in July 2017 in order to obtain an opinion regarding four requests regarding hypertension: (1) "[w]hether it is at least as likely as not that the Veteran's hypertension had its onset in service or manifested within one year of separation from service" and noting that several blood pressure readings in service should be considered, (2) discussion of "the National Academy of Sciences Institute of Medicine study stating that there is "limited or suggestive evidence of an association" between exposure to herbicides and hypertension," (3) "[w]hether it is at least as likely as not that the Veteran's hypertension is caused by his service-connected PTSD. In answering this question, please discuss the VA study that indicates a possible link between PTSD and heart disease (http://www.research.va.gov/currents/spring2015/spring2015-8.cfm)," and (4) "[w]hether it is at least as likely as not that the Veteran's hypertension is aggravated by his service-connected PTSD." The physician was instructed that the Veteran was noted to not have an abnormality related to hypertension prior to service. An Independent Medical Opinion (IMO) was obtained in July 2017 from a physician. The physician noted it was "less likely than not that the Veteran's hypertension related to military service and/or secondary to herbicide exposure and/or PTSD based." The physician noted she had reviewed the record and noted that the Veteran was presumed sound upon entrance into service. The physician noted several evaluated blood pressure readings in December 1974 and July 1972, but they were readings were "acute, self-limited[,] and transient." Additionally, the physician noted that the Veteran denied a history of high or low blood pressure on his separation examination. Therefore, it was less likely than not the Veteran's hypertension was related to or aggravated by his time spent on active duty. The physician noted there was no "complaints, diagnosis, treatment, injury and/or events related to hypertension" during the presumptive period and "it was it is LESS LIKELY THAN NOT that the Veteran's claimed hypertension related to and/or was aggravated one year following military service." The physician discussed current internal medicine and orthopedic literature on the etiology and nature of hypertension reveal a number of factors cause hypertension, including "genetic factors, psychological stress, and environmental and dietary factors." The physician noted that the IMO and the VA do not recognize hypertension as a presumptive condition. The physician stated: Furthermore, the current research and review process of the health effects in Vietnam Veterans and exposure to herbicides were silent for a relationship of AO exposure and hypertension. Moreover, and with review of the National Academy of Science Institute of Medicine study statement of "limited or suggestive evidence of an association" between exposure to herbicides and hypertension, the suggestive statement remains merely speculative and without statistical significance of objective medical based, clinical evidence to support a nexus between exposure to herbicides and hypertension, at this time. Therefore, and in response to [the remand], it is LESS LIKELY THAN NOT that the Veteran's claimed hypertension related to, was presumptive of and/or was aggravated by an exposure to Agent Orange. Turning to PTSD causing hypertension, the physician noted "in the broadest definition, the National Center for PTSD states 'PTSD is an anxiety disorder that some people get after seeing or living through a dangerous event.'" The physician again recounted the numerous factors that cause hypertension and reported: Moreover, current internal medicine and mental health literature lacks sufficient objective medically-based, clinical evidence to support a nexus between and/or aggravation for PTSD related hypertension. Although new VA studies are evaluating a "suggestive" possible links between PTSD and heart disease, at this time, the clinical and research data remains merely speculative and without significant statistical power and significance in this priority population. (Please see http://www.research.va.gov/current/spring 2015/spring 2015-8.cfm). Moreover, . . . the Veteran does not have a past cardiovascular history of heart disease, to include ischemic heart disease. Therefore, no comment, and/or academic or hypothetical discussions are warranted at this time because the medical situation does not apply to this Veteran. For these reasons, and in response to [the Remand] It is LESS LIKELY THAN NOT that the Veteran's claimed hypertension relates to, nexus between and/or was aggravated by his service connected PTSD. Moreover, the Veteran does not carry a current diagnosis of ischemic heart disease; NO comment is warranted on the research.va.govcurrent/spring 2015 VA study suggestion of a "possible link between PTSD and heart disease." The examiner made some statements regarding the 1972 hospitalization, including noting anxiety and right-sided cramp pain could cause evaluated blood pressure. However, after additional service records discussing dengue fever were obtained, an addendum IMO was obtained from the physician. This supersedes the prior opinion regarding the 1972 hospitalization. The examiner noted "Dengue fever is a mosquito-borne viral disease occurring among travelers in Southeast Asia. There is a 3-7 day incubation period with symptoms resolution within a 10 day period. The signs and symptoms of infection include high fever, severe myalgia, headache, retro-orbital pain, rash (maculopapular, mottled[,] or petechial) with thrombocytopenia, leukopenia." The examiner noted the Veteran elevated blood pressure. The examiner noted the normal blood pressure during the separation and entrance examination and "it is at least as likely as not that the Veteran's August 1972 presentation of suspected Dengue fever with elevated blood pressure was an acute, transient[,] and self-limited event related to his tropical medical infection because his blood pressure prior to and after suspected Dengue fever was within normal limits." Therefore, "it is LESS LIKELY THAN NOT that the Veteran's hypertension had its onset in service." The Veteran has provided lay statements regarding his belief that his hypertension started in service. The Board acknowledges that lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran is competent to state what he was told. In this case, he was told he had elevated blood pressure in service. He in fact did have high blood pressure readings in service. However, the Veteran denied a history of high or low blood pressure at separation. The Veteran was not treated for hypertension for a number of years after service. Therefore, while competent, such a statement is not credible, as it contradicts the evidence of record, and is entitled to low probative value. Here, despite elevated pressure readings during service, hypertension was not "noted" during service and he did not have characteristic manifestations sufficient to identify hypertension as a disease entity. Rather, at the separation examination, the vascular system and blood pressure were normal. Such findings are inconsistent with continuity of symptomatology. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). To the extent the Veteran was told he had hypertension, he is competent to report what he was told. However, again, his statements regarding hypertension are not credible, as they are contradicted by the medical evidence. The Veteran denied a history of high or low blood pressure at separation and the heart and vascular systems were normal. To the extent that the Veteran's representative or the Veteran claimed a relationship between PTSD-related anxiety in service, the Veteran and the representative are not competent themselves to state what caused hypertension. A causal relationship between hypertension and PTSD-related anxiety, as opposed to lay observable symptoms of each disorder, is not a factual matter of which a lay person can have firsthand knowledge. They have not stated upon what basis such a statement has been made and they do not have the education, training, or experience to state what caused the Veteran's hypertension. As a result, all of the above contentions are of low probative value compared to the IMO. The physician who gave the IMO noted elevated blood pressure readings were transient and self-limited and resolved. This is supported by the service treatment records, which note the Veteran had normal blood pressure at separation and no heart or vascular issues. The physician who provided the IMO reviewed the Veteran's file, including the Veteran's medical history and provided conclusions based on sufficient facts and data. Therefore, this opinion is entitled to significant weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). It was based upon sufficient facts or data, was the product of reliable principles and methods, and was the result of principles and methods reliably applied to the facts. The physician gave a detailed opinion regarding the Veteran's claim as stated above. As such, while the Board has considered the Veteran's lay statements, to the extent he argues continues symptoms since service, such statements lack credibility; they do not outweigh the probative medical opinions. At this time, there is no accepted proof that the remote onset of hypertension occurred in, or within one year of, service or are otherwise related to service. In addition, the Veteran did not have the characteristic manifestations sufficient to identify the disease entity. At separation, the Veteran had a normal examination for the relevant areas. On his Report of Medical History, the Veteran listed no high or low blood pressure history. There is no competent evidence of hypertension, as opposed to isolated elevated blood pressure readings, until many years post service. For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for hypertension. The benefit-of-the-doubt doctrine is therefore not for application, and the claim for service connection for hypertension must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Chronic Obstructive Pulmonary Disease (COPD) The Veteran contends he had COPD symptoms in service. See lay statement received October 2004 (claimed as a lung disability, interpreted as a claim for COPD). The Veteran noted a history of pain or pressure in chest on his Report of Medical History at induction in November 1970. His November 1970 pre-induction examination noted "normal" for lungs, chest, mouth, and throat. The Veteran reported instances of chest pains in service, worsened when coughing, generally with a cold or without a diagnosis of an underlying illness. In his August 1974 separation examination, the Veteran reported some shortness of breath with pressure in chest occasionally since 1970, associated with moderate indigestion controlled by medication. His lungs and chest and mouth and throat were noted as normal by the examiner. The Veteran endorsed "yes" for shortness of breath and pain or pressure in chest on his August 1974 Report of Medical History, but "no" for chronic cough. The Veteran was seen at an at the VA emergency room in November and December 2000 and diagnosed with bronchitis/early pneumonia. He was diagnosed with COPD around this time. See, e.g. October 2017 VA examination (reporting Veteran stated he was diagnosed at this time). In July 2017, the Board remanded for an opinion regarding: Whether it is at least as likely as not that the Veteran's COPD had its onset in service or is otherwise etiologically related to service. In rendering this opinion, the evaluator should consider the March and July 1972 service treatment records which reveal chest pain, the August 1974 service treatment record which notes shortness of breath, and any hospitalization records from [a military] hospital if located. The Veteran's hospitalization records referenced in the remand were for hospitalization for possible dengue fever in July and August referenced above in the prior section. The examiner, a physician, reported in an opinion dated October 2017 that "[i]t is less likely than not (less than 50 percent) the Veteran's COPD had its onset in service or is otherwise etiologically related to service." The examiner noted that the Veteran reported he was diagnosed with COPD 25 years before (sometime in the mid-1990s). The Veteran reported "daily wheezing, non-productive cough, dyspnea on exertion, chest tightness over 'past 15 years.' He uses albuterol inhaler about 3-4 times per day over past 2 years." The Veteran had not been hospitalized in the last year. The Veteran reporting smoking 1/2 to 1 pack of cigarettes a day since he was 12 and he continued to smoke daily. The examiner noted reports of treatment for congestion in service and that he was evaluated as normal at separation. The examiner noted the 1974 hospitalization and that the Veteran stated he had "fully recovered" on his separation examination. The examiner noted no treatment records from 1974 to 1999 and that the most important risk factor was cigarette smoking. The Veteran endorsed a history of pain in chest on both induction and separation, but the separation examination documented that shortness of breath was related to indigestion and pressure in the chest and there was no documentation of wheezing at separation. The VA examiner noted there was no diagnosis of any type given at separation and specifically there was no problem or abnormality found, instead the Veteran was found as normal. The VA examiner further reported that the Veteran was diagnosed with COPD 25 years after service and after 37 years of smoking. Therefore, "COPD is less likely than not (less than 50 percent probability) incurred or caused or had its onset during military service. The [V]eteran's claimed condition of COPD is most likely secondary to his 54 pack-years smoking history." The Veteran has provided lay statements regarding his believe that his COPD started in service. The Board acknowledges that lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of disability or symptoms subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran is competent to testify to wheezing, coughing, chest tightness, and other lay observable symptoms. The Board acknowledges that the Veteran claims his "in-service symptoms persisted on a continual basis until the current diagnosis." See January 2018 IHP. To the extent that his claim symptoms are the same as his current symptoms, he is competent to make such a statement. However, these statements are contradicted by a probative medical opinion and by the Veteran's own statements that his symptoms only started about 15 years prior. The physician who provided the October 2017 medical opinion reviewed the Veteran's file, recited the Veteran's medical history in the VA examination report, examined the Veteran (in the prior December 2016 examination), and provided conclusions based on sufficient facts and data. Therefore, this opinion is entitled to significant weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As such, while the Board has considered the Veteran's lay statements, to the extent he argues continues symptoms since service, such statements lack credibility; they do not outweigh the probative medical opinion. At this time, there is no accepted proof that the remote onset of COPD occurred in service or is otherwise related to service. At separation, the Veteran had a normal examination for the relevant areas. On his Report of Medical History, the Veteran listed a history of respiratory symptoms. However, COPD was not identified and a VA examiner found that these were not related to COPD and COPD was due to a multiple year history of smoking. There is no competent evidence of COPD until many years post service. For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for COPD. The benefit-of-the-doubt doctrine is therefore not for application, and the claim for service connection for COPD must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Headache Disorder The Veteran contends that he has headaches or migraines secondary to head trauma in service. See Veteran's lay statement received in October 2004 (reporting continuing headaches two or three times a week). Alternatively, the Veteran contends his headaches have some relationship to PTSD. See Veteran's correspondence received in November 2004 ("I was diagnosed with Post Traumatic Stress Disorder (PTSD) which is direct[ly] link[ed] to my headaches."). In addition, as a third theory of entitlement, the IHP notes the Veteran's headaches pre-existed service and "in-service treatment, clearly and unmistakably, indicates an increase in severity of the conditions during active military service." The Veteran reported a history of frequent or severe headaches during his November 1970 Report of Medical History and there is a notation of "nervous headaches" in the physician's summary. In the November 1970 entrance examination itself, the Veteran's head and neurology were noted as normal and there was no report of headaches. The Veteran received treatment for headaches in service in March 1971, twice in November 1971, July 1972 (fever-related headache), January 1973, February 1974 (sinus headache), June 1974, and August 1974. Symptoms included multiple day headaches with full body ache, tension headaches, and one instance of headaches and nausea caused by the flu. The June and August 1974 noted that symptoms of headaches, nausea, and rash when serving around fuels and attributed it to "flu/fuel prob." In the August 1974 separation examination, the Veteran reported a history of severe and frequent headaches since childhood, averaging twenty a month, and controlled by medication. His Report of Medical History the same month also notes frequent headaches and dizziness or fainting spells. The Veteran claims he continues to have headaches. The Board remanded the claim in July 2017 for the examiner to answer the following directives: [1] Whether it is at least as likely as not that the Veteran's headache disorder noted on the November 1970 report of medical history physician's summary section increased in disability during his active service. [2] If the evaluator determines that it is at least as likely as not that the headache disorder increased in disability during the Veteran's active service, the evaluator must provide an opinion as to whether there is clear and unmistakable evidence (i.e. evidence that is undeniable) that such increase in the disability was due to the natural progression of the headache disorder. In answering these questions, the evaluator should review the November 1970 report of medical history; the August 1974 report of medical examination; and the March 1971, November 1971, February 1974, June 1974, and August 1974 service treatment records which include reports of headaches. [3] Whether it is at least as likely as not that the Veteran's headache disorder is caused or aggravated by his service-connected PTSD. The examiner noted the following for one: It is less likely than not (less than 50 percent probability) that the Veteran's headache disorder on the November 1970 report of medical history physician's summary section increased in disability during his active service . Rationale: There is no evidence that the [V]eteran's headache disorder increased in disability during his active service from his pre-induction examination dated 11/6/1970. The examiner did not document severity or frequency of his headaches prior to active duty. Although the examiner wrote during his separation examination dated . . . [that] "[p]atient states that frequent headaches since childhood (approximately 20 per month)," there is no indication that his headaches worsened in severity during active duty. The examiner noted the following for two: "The claimed condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury, or illness. " The rationale noted the notations of headaches in service and the notations of "yes" in the Reports of Medical History. At separation, the examiner noted that "[p]atient states frequent headaches since childhood (approximately 20 per month) severe, adequately controlled with medication" and that the Veteran did not give a frequency of headaches at induction and treatment in service was infrequent, only a handful of times over four years. The Board additional notes that some of the headaches listed in service are attributed to other illnesses, such as the flu, fever, sinus, or possible exposure to fuel fumes. The examiner also noted that the Veteran "currently has 3-4 episodes of headaches per month which is a decrease in the frequency of headaches since separation from the military." The Veteran, as noted by the examiner, did not require daily prophylactic medications to control his headaches or prescription medication. The Veteran is competent to report head pain, as well as severity and frequency. However, his statements regarding some type of traumatic injury to his head or a relationship to PTSD are not credible. Regarding the claim for relationship to PTSD, the examiner noted that the Veteran had previously reported that his "headaches are not triggered by PTSD[,] but if you work on my nerves I may have a slight headache." The examiner reported treatment of PTSD did not note headaches. There is no noted head trauma in service nor any documentation or lay explanation of in-service head trauma. In fact, the Veteran's representative stated that headaches clearly and unmistakable pre-existed service. See January 2018 IHP ("The evidence of record establishes the claimed conditions existed prior to active military service. The evidence of record establishes the Claimant was treated for the claimed conditions during active military service. The Claimant asserts the in-service treatment, clearly and unmistakably, indicates an increase in severity of the conditions during active military service."). In any event, his Report of Medical History at separation and entrance, as well as his separation examination, all show that his headaches clearly and unmistakably pre-existed service. Therefore, the Veteran's claim that his headaches are trauma-related is not supported by the medical evidence or service records. Likewise, a finding of PTSD related headaches cannot be supported by the evidence, as headaches pre-existed the PTSD (as explained below) and are not associated with PTSD in medical records. While considered, the Veteran's competent statements regarding in-service onset or secondary to PTSD after service are not credible, as they contradict the medical evidence, and are entitled to low probative value. The Board has considered whether service connection based on aggravation basis, as well as direct basis, is warranted. As noted above, the Veteran's entrance examination, as opposed to his Report of Medical History, noted normal for relevant areas. See 38 C.F.R. § 3.304(b)(1)("History of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions.") Because a headache disorder was not noted at entrance, the Veteran is entitled to a presumption of soundness. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran's disability was both pre-existing and not aggravated by service. The government may show a lack of aggravation by establishing that there was no increase in disability during service or that any increase in disability was due to the natural progress of the pre-existing condition. 38 U.S.C. § 1111; Wagner v. Principi, 370 F.3d 1089 (Fed. Cir.2004) Here, the presumption of soundness is rebutted by clear and unmistakable evidence. While the Veteran noted only a history of headaches at entrance, the examining physician wrote in the "Physician's summary" section of the Report of Medical History that the Veteran had "nervous headaches." The separation examination reported frequent headaches (20 a month) since childhood, controlled by medication. The examiner who gave the medical opinion and the Veteran's representative, in the most recent January 2018 IHP, both discussed whether the headache disorder was aggravated as the primary theory of entitlement. As pointed out by the VA examiner, the headaches improved during service and following service. Prior to service, the Veteran headache frequency was 20 times a month and was noted as controlled by medication in service. Currently, the Veteran did not take "daily prophylactic medications to control his headaches or prescription medication." The Veteran's claims regarding aggravation, while competent, are not credible. The Veteran's statement regarding aggravated headache disorder is contradicted by the medical evidence as reported by the Veteran in his service and VA treatment records. They do not outweigh the probative medical opinion, as it was given by a competent medical professional with knowledge of the facts of the case, provided a provided a reasoned analysis, and applied medical knowledge to the facts of the case. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As such, while the Board has considered the Veteran's lay statements, to the extent he argues aggravation in service, such statements lack credibility, and they do not outweigh the probative medical opinions. The Board notes that the VA examiner used the incorrect legal terminology regarding natural progress. However, the examiner clearly established that there was not a permanent increase in severity since there had been actual improvement. In short, the probative evidence shows there was no aggravation of headache disorder by service. The Veteran's claims to the contrary are not supported by the record, and the claim must be denied. The benefit-of-the-doubt doctrine does not apply. Bilateral Foot Disability In a letter received in November 2006, the Veteran claimed injury to his feet in service and that he currently has degenerative arthritis of both feet due to training in service. He contended his "condition" was not diagnosed prior to separation from service and his foot problems were due to trauma from running in combat boots. The Veteran's representative, in the January 2018 IHP contended that the Veteran's bilateral foot disability pre-existed service and was worsened in service. The Veteran's service entrance examination in November 1970 noted "mild pes planus." The Veteran did not note a history of foot problems including foot trouble, broken bones, arthritis, or bone, joint, or other deformity on his November 1970 Report of Medical History. The Veteran had treatment in service for foot blisters in August 1971. There were no other in-service treatments of record. The Veteran's August 1974 separation examination reported normal feet. He again did not report a history of foot trouble; broken bones; arthritis; or bone, joint, or other deformity in his August 1974 Report of Medical History. In an October 2003 VA primary care note, the Veteran noted he dislocated his right great toe at some point prior. In December 2003, a VA treatment record reported arthritis in the great toe. The Veteran arrived at a VA emergency room in January 2004 with complaints of injury in July (no year given) with continuous pain since. January 2004 X-rays in VA treatment records note that there were no previous examinations. Impression was "[m]arked degenerative changes seen in bilateral first metatarsophalangeal joints . . . Bilateral plantar calcaneal spurs." There were also arthritic changes in the distal aspect of the toe with no fracture. A podiatrist diagnosed the Veteran with hallux rigidus in 2005. A VA examination in December 2016 noted the Veteran had bilateral pes planus, hallux valgus and rigidus, and degenerative arthritis based on physical examination and X-rays that same month. Impression from X-rays was "1. [d]egenerative changes in the first metatarsophalangeal and interphalangeal joint, as described. 2. Diffuse demineralization of the visualized bones. [and] 3. Calcaneal spurs." In July 2017, the Board remanded for an addendum opinion on the etiology, nature, and onset regarding the Veteran's foot disability. Specifically, the Board asked the VA examiner to address: [(1)] Whether it is at least as likely as not that the pes planus noted on the November 1970 report of medical examination increased in disability during his active service; [(2)] "If the evaluator determines that it is at least as likely as not that the pes planus increased in disability during the Veteran's active service, the evaluator must provide an opinion as to whether there is clear and unmistakable evidence (i.e. evidence that is undeniable) that such increase in the disability was due to the natural progression of the pes planus. [(3)] For each other foot disability diagnosed, to include bilateral hallux valgus, bilateral hallux rigidus, and bilateral degenerative arthritis, the examiner should opine as to whether it is at least as likely as not that the Veteran's foot disorder had its onset in service or is otherwise etiologically related to service. The examiner reported that to question (1) "The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event, or illness." The rationale was The [V]eteran reports that he wore tight boot "while in Vietnam because I needed a wide width." He states that he was issued new boot due to blisters later. The [V]eteran was noted to have mild pes planus on his pre-induction examination . . . Review of his STRs revealed complaints of blisters on both feet dated [in August] 1971. Flatfeet have been shown to be an independent risk factor for foot blisters during road marching. Those with flat feet were reported to have a 37% increased risk of developing blisters. The pes planus caused a temporary increase in disability as evident of the development of blister. There were no other foot complaints during service. The [V]eteran checked no to foot trouble on his separation examination. For (2), the examiner reported "[i]t is less likely than not (less than 50 [percent] probability) that the pes planus increase in disability during the Veteran's active service." The examiner repeated the above information for question (1) regarding change of blisters and noted there was no treatment again in service that the separation examination was normal for his feet, and that blistering on his feet was temporary. The Veteran had no reported foot issues until January 2004 (as outlined above), approximately 30 years after service. For (3), the examiner reported that "[i]t is less likely than not that each other foot disability diagnosed, to include bilateral hallux valgus, bilateral hallux rigidus, and bilateral degenerative arthritis is at less likely than not (less than 50 percent probability) had it onset or is otherwise etiologically related to service)." The examiner explained that the Veteran was diagnosed nearly 30 years after service, that hallux rigidus ("HR") was a disorder causing reduced range of motion of the great toe due to osteoarthritis of the first metatarsophalangeal and is present in about 6 percent of middle age and older adults and is likely due to osteoarthritis. The examiner explained that "[h]allux valgus, metatarsus adductus, and a flattened [first metatarsophalangeal] joint are more common in individuals who develop HR." In essence, these disabilities were related to osteoarthritis, which developed after service. The examiner reported that pes planus causes a temporary blister in 1971 and there were no other foot complaints in service or at separation. Based on the 30 year difference between emergence of a foot disability (complaints of great toe joint point pain and arthritis) and it was less likely (50 percent or less) incurred or caused by military service. The Board acknowledges that lay assertions may serve to support a claim for service connection by supporting the occurrence of lay-observable events or the presence of a disability or symptoms subject to lay observation. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Layno v. Brown, 6 Vet. App. 465, 470 (1994). The Veteran is competent to report pain in his feet, blistering, or that he has decreased movement in his feet. The Veteran at one point contended his foot disability started in service. Such a statement is not credible. The Veteran denied any foot trouble on separation and entrance Reports of Medical History. Besides, one instance of blisters, service treatment records do not report foot problems. His separation examination was normal for feet. For the disability of the feet, described above, besides pes planus (discussed below), there was no medical treatment for a number of decades after service. Some thirty years after service, at the time he first reported issues with his feet, leading to the current diagnosis, he described his foot disability as recent occurrence due to a post-service injury. Therefore, the Veteran's statements of in-service occurrence are not credible and contradict the evidence of record. More recent statements suggest his contention is that his pre-existing pes planus worsened in service and ultimately caused his current disability. This is not shown by his service treatment and VA records. Pes planus was noted at entrance and the Veteran had temporary blistering early in service, followed by no further treatment. He denied relevant history at separation. The examination reported normal feet. The Board notes that the Veteran had noted mild pes planus at entrance into service, but at separation his feet were normal, which indicates no increase in severity. He denied a relevant history of foot trouble at both separation and entrance, which shows that the Veteran did not indicate his feet had worsened in service. Again, the Veteran's statements of in-service worsening of a pre-existing pes planus are not credible and contradict the evidence of record. The Board finds that the medical evidence outlined above to be more probative then the Veteran's statements. The medical professional that provided the medical opinion is competent to provide an opinion on this matter. The examiner had knowledge of the Veteran's medical history and examined the Veteran, and provided conclusions in medical documents based on sufficient facts and data, including diagnostic testing. Therefore, this opinion is entitled to significant weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As such, while the Board has considered the Veteran's lay statements, as they lack credibility, they do not outweigh the more probative medical opinion, which links his current foot disabilities to arthritis, which developed after many years after service. In short, the credible and probative evidence establishes that the Veteran's (non-pes planus) foot disability was not manifest during service and are not due to service. Bilateral foot arthritis did not manifested during service or within one year of service. In addition, the Veteran did not have the characteristic manifestations sufficient to identify the disease entity. At separation, the Veteran had a normal examination. The Veteran did not list any issues on his Report of Medical History relevant to the feet. There is no competent evidence of arthritis or other foot disability (besides the pes planus) until many years post service. There is no evidence of worsening of pes planus in service. The lay assertions to the contrary are not credible and are outweighed by the probative medical opinion. For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for a bilateral foot disability. The benefit-of-the-doubt doctrine is therefore not for application, and the claim for service connection for a bilateral foot disability must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for hypertension, to include as due to herbicide exposure or to a service connected disease or injury, is denied. Entitlement to service connection for COPD is denied. Entitlement to service connection for a headache disorder, to include as due to a service connected disease or injury is denied. Entitlement to service connection for a bilateral foot disability is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs