Citation Nr: 1823027 Decision Date: 04/16/18 Archive Date: 04/25/18 DOCKET NO. 13-13 080 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for diabetes mellitus, type I, to include as secondary to service-connected major depressive disorder with generalized anxiety disorder. 2. Entitlement to service connection for a bilateral foot disorder, to include as secondary to diabetes mellitus, type I. WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD Koria B. Stanton, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1979 to August 1980. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Los Angeles, California. Jurisdiction of the Veteran's claims file was subsequently transferred to the RO in Atlanta, Georgia. In December 2012, the Veteran testified at a hearing before a Decision Review Officer (DRO) at the RO, and in May 2014 and May 2017, she testified at Board hearings before the undersigned Veterans Law Judge sitting in Washington, D.C. Transcripts of these hearings have been associated with the record on appeal. Further, the Board denied her request for a third Board hearing in January 2018. In a June 2014 decision, the Board granted service connection for the Veteran's psychiatric disorder and remanded the issues of entitlement to service connection for diabetes mellitus, type I, and a bilateral foot disorder for further development. In February 2015, the Board denied such claims. The Veteran subsequently appealed the denial of such issues to the United States Court of Appeals for Veterans Claims (Court), which, in March 2016, issued a Memorandum Decision vacating and remanding the matters for further consideration. In the interim, the Veteran filed a motion to reverse or revise the February 2015 Board decision on the basis of clear and unmistakable error. However, such motion, which will be addressed in a Board decision issued at a later date, is rendered moot by the Court's vacatur of the February 2015 decision. Thereafter, in November 2016, the Board remanded the claim for service connection for diabetes mellitus, type I, and a bilateral foot disorder for additional development. In November 2017, the Board sought an expert medical opinion from the Veterans Health Administration (VHA) pursuant to VHA Directive 1602-01. Such opinion was rendered in December 2017. In February 2018, the Veteran was provided a copy of the opinion and allowed 60 days to submit additional evidence and/or argument, which was received later the same month. The Board notes that, subsequent to the issuance of the February 2017 supplemental statement of the case, the Veteran submitted additional evidence for consideration in her appeal, to include copies of treatment records and an October 2017 VA examination pertinent to her service-connected psychiatric disorder. She explicitly waived Agency of Original Jurisdiction (AOJ) consideration of such evidence in February 2018 and, furthermore, her substantive appeal was received in March 2013. See 38 U.S.C. § 7105(e)(1) (2012)); Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Public Law No. 112-154, 126 Stat. 1165. Therefore, the Board may properly consider such evidence. The Board is also cognizant that additional VA treatment records and vocational rehabilitation records were associated with the file subsequent to the February 2017 supplemental statement of the case. While the Veteran has not waived AOJ consideration of such evidence, the Board finds that it is either duplicative of the evidence previously considered or irrelevant to the issues on appeal. 38 C.F.R. § 20.1304(c) (2017). In this regard, the newly received records only document ongoing treatment for the Veteran's service-connected psychiatric disorder, with complaints similar to those previously of record and considered by the AOJ, and her diabetes mellitus and bilateral foot disorder, diagnoses of which were already documented in the record and considered by the AOJ. Therefore, the Board finds no prejudice to her in proceeding with a decision at this time. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. Diabetes mellitus, type I, is not shown to be causally or etiologically related to any disease, injury, or incident during service, did not manifest within one year of the Veteran's service discharge, and is not caused or aggravated by her service-connected major depressive disorder with generalized anxiety disorder. 2. A bilateral foot disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, arthritis did not manifest within one year of the Veteran's service discharge, and such is not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for diabetes mellitus, type I, have not been met. 38 U.S.C. §§ 1101, 1112, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). 2. The criteria for service connection for a bilateral foot disorder have not been met. 38 U.S.C. §§ 1101, 1112, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Preliminary Matters The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991); Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). While the Veteran reported in a February 2017 written correspondence that she was not given the opportunity to identify any outstanding private or VA treatment records, to specifically include private treatment records from Cedar Sinai Medical Center and Dekalb Medical Center, such records were obtained in March 2017 and associated with the record. Additionally, while the Veteran reported that the February 2017 supplemental statement of the case and the December 2016 VA diabetes mellitus examiner referenced a November 2014 VA examination report, which included an opinion addressing whether her diabetes mellitus, type I, was etiologically related to her psychiatric disorder that the Court previously determined to be was inadequate, the Board does not herein rely on the previously determined inadequate opinion, or the December 2016 opinion, in denying her claim on a secondary basis. Finally, the Board notes that the Veteran has challenged the adequacy of the December 2017 VHA opinion on the grounds that the examiner did not consider her most up-to-date treatment records, to specifically include an October 2017 VA examination, pertaining to the nature and severity of her service-connected psychiatric disorder. However, upon review of such records, the Board finds that, the VHA examiner specifically cited findings from the October 2017 VA examination. Moreover, the remainder of the record he considered clearly document the nature of the Veteran's complaints and resulting functional impairment related to her psychiatric disorder. Therefore, the Board finds that the December 2017 VHA examiner considered all pertinent evidence of record in rendering his opinion, even if such was not specifically cited. The Veteran has not alleged any other deficiency with respect to VA's duties to notify or assist. See Scott, supra (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 duty to assist argument). II. Analysis Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). Where a veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, such as diabetes mellitus 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, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309(a) is not shown to be chronic during service or the one year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303(b). However, the use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309(a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Diabetes Mellitus, Type I At her hearings and in documents of record, the Veteran alleged that her diabetes mellitus, type I, is directly related to her military service, or in the alterative, secondary to her service-connected major depressive disorder with generalized anxiety disorder. In this regard, she claimed that, although she was formally diagnosed with diabetes mellitus in 1991, many years after her service discharge in August 1980, as such is type 1, she must have had the disorder upon entrance into service. Additionally, the Veteran reported that she had gestational diabetes during pregnancy and was pregnant at the time of her separation from service. She also notes that urinalysis performed during service showed small ketones and argues that such supports the finding that she was diabetic during service. She further reported that she had symptoms throughout the time of her service that were indications that she had diabetes, to include skin and stomach problems, irritability, and slow healing infections. The Veteran also alleges that her service-connected major depressive disorder with generalized anxiety disorder caused or aggravated her diabetes mellitus, type I. In this regard, she asserted that, as a result of her service-connected psychiatric disorder, she would fail to take her insulin, which negatively affected her diabetes. She further asserted stated that, as a result of such service-connected disability, she suffers panic attacks and becomes extremely ill in the form of nausea and vomiting and, as a result, her blood sugar levels increase to the point that she requires medical care. Therefore, the Veteran alleges that service connection for diabetes mellitus, type I, is warranted. The Veteran's service treatment records (STRs) reveal there is no indication of diagnosis of diabetes upon entrance in service, during service, or at the time of separation of service. In fact, on her September 1979 enlistment examination, her urinalysis with respect to albumin and sugar were negative. In an undated record, which was noted to have been created on her first day at basic combat training, the Veteran complained of a headache, nervousness, nausea, and stomach cramps. The assessment was hysterical behavior. In November 1979, the Veteran complained of dizziness and headaches. It was noted that her immunizations were done the day before. A subsequent record reflects complaints of abdominal pains with vomiting or diarrhea. The impression was shot reaction combined with hysterical reaction. Additionally, in November 1979, the Veteran complained of menstrual cramps and a right eye sty. The impression was mild post-immunization myalgia. In January 1980, it was noted that the Veteran complained of nausea with dizziness for the prior four days. Her serum HCG was negative. In April 1980, the Veteran complained of a right eye problem and a cold. A chest X-ray was negative. A subsequent record dated the same month revealed that, since the age of 12, her right eye lid swelled up and gave her headaches certain times of the year. In May 1980, the Veteran complained that her throat and stomach hurt. Ultimately, she was diagnosed with depression and suicidal ideation, and adjustment reaction. Blood work from May 1980 revealed +2 ketones. In June 1980, the Veteran complained of morning sickness with vomiting for two days. HCG was negative. A week later, it was noted that she had stopped taking her birth control pills in the middle of the package. She also reported headaches. HCG was negative again. The assessment was stress adjustment reaction. In July 1980, the Veteran complained of nausea, vomiting, belching, decreased energy, and increased sleep. Ultimately, it was determined that she was pregnant. Subsequent records show a positive HCG test and complaints that were found to be normal pregnancy symptoms and, later in July 1980, she was diagnosed with candida. Blood work in July 1980 revealed small ketones, glucose of 87, and 1+ protein. The Veteran's STRs further reveal that, on her July 1980 Report of Medical History for Separation, she checked no to sugar or albumin in urine. On the accompanying Report of Medical Examination for Separation, her urinalysis with respect to albumin and sugar were negative and it was noted that the Veteran was 8 weeks pregnant at the time. Post-service VA treatment records reflect treatment for diabetes mellitus type I, to include through an insulin pump, and emergency room treatment and hospitalization for diabetic ketoacidosis. Such records further reflect that the Veteran was diagnosed with diabetes mellitus type I with a variously reported onset date of approximately 1990, 1991, and 1992. Additionally, post-service private treatment records reflect the Veteran's complaint of nausea and vomiting in December 2000. Such record noted a diagnosis of diabetic ketoacidosis, and indicated that the Veteran was started on an insulin drip, which improved her blood sugar levels. A January 2001 private treatment record noted an assessment of diabetes mellitus, type I, under poor control with severe stress due to psychosocial problems. A May 2002 private treatment record indicated an assessment of diabetic ketoacidosis due to a crimped subcutaneous set in a person with marked psychosocial distress. A May 2003 private treatment record noted diagnoses of a panic disorder and diabetes mellitus. Additionally, an April 2004 private treatment record reflected the Veteran's complaint of abdominal pain and vomiting, and noted an impression of vomiting and anxiety. An April 2005 private treatment record noted an assessment of an anxiety reaction and vomiting. A May 2005 private treatment record revealed diagnoses of nausea and vomiting, poorly controlled diabetes, and anxiety. A September 2005 private treatment record indicated an assessment of an anxiety reaction. An October 2005 private treatment record noted an assessment of diabetic ketoacidosis, and intractable nausea and vomiting. A May 2006 private treatment record revealed diagnoses of anxiety and hyperglycemia. Furthermore, an August 2007 private treatment record indicated that the Veteran was diagnosed with type 1 diabetes in 1991 and such had been maintained on insulin since such time. Such record further indicated that that the Veteran had brittle diabetes, due to poor control over many years, and developed complications, to include retinopathy, and peripheral and autonomic nervous system neuropathy. It was also noted that the Veteran had been hospitalized on numerous occasions with gastrointestinal problems and diabetic ketoacidosis. Her treatment provider indicated that, because of the Veteran's multiple medical problems, she had major depression with associated anxiety, and such problems, all of which were related to her diabetes, had rendered her essentially unemployable. An October 2013 private treatment record reported an impression of a panic attack, anxiety, nausea, and diabetes mellitus, type I. Moreover, a December 2015 private treatment record noted diagnoses including psychogenic vomiting, diabetes mellitus, type I, and gastroparesis. An additional December 2015 private treatment record revealed an impression of non-specific nausea and vomiting, although likely suspect gastroparesis; and diabetes mellitus, type I, with noted complications, poorly controlled. March 2016 private treatment records indicated the Veteran's complaint of a panic attack and noted a diagnosis of anxiety. She stayed in the emergency room overnight due to a discharge diagnosis of gastroenteritis, status post hypoglycemic episode. Additional records continue to reflect complaints and treatment for the Veteran's anxiety. Social Security Administration (SSA) records show that the Veteran was found to be disabled due, in part, to diabetes mellitus. The Veteran was afforded a VA examination in November 2014. After examining the Veteran and reviewing the record, the VA examiner noted a diagnosis of diabetes mellitus, type I, as of August 9, 1991. She opined that the Veteran's diabetes mellitus, type I, was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale for the opinion, the examiner reported that a review of the Veteran's STRs revealed that such were silent for a diagnosis of diabetes pre-service, during active service, or on her exit examination; however, such revealed, as discussed in detail above, treatment for candida (yeast infection) in July 1980, which literature supported pregnancy as a cause of a vaginal yeast infection. Additionally, the examiner observed that the Veteran received three negative HCG tests (pregnancy tests) in January 1980, and twice in June 1980. She further observed that the July 1980 blood work clearly stated that the Veteran's glucose was 87, which was normal and warranted no further diabetic work-up at that time. Hence, the urine specimen at such time reflected results as glucose negative and yellow, cloudy, protein 1+, WBC 2-3, RBC 0-2, Epithelia cells TNTC (too numerous to count), bacteria moderate, ketones small, mucus heavy, which, according to literature, are reflective of a urinary tract infection. Furthermore, the November 2014 VA examiner indicated that the Veteran's July 1980 separation examination did not show any problems related to sugar or albumin in urine. She further indicated that STRs in June 1980 and July 1980 revealed complaints of nausea and vomiting to stress adjustment and pregnancy. Additionally, while the Veteran had multiple sick call notes for conjunctivitis and a sty on the eye, such were conditions the Veteran stated she had prior to active service. The examiner noted that the Veteran's records reflected one occasion of small amount of ketones upon urinalysis and no other diabetic symptomatology. In this regard, the examiner observed that the records did not reflect skin and stomach problems (other than pregnancy or adjustment disorder), or slow healing infections during service. In this regard, the Board notes that it appeared that the examiner inadvertently stated that "the Veteran's current diabetic condition was incurred in or caused by her active duty service in the Army"; however, her ultimate conclusion was that the Veteran's diabetes was unrelated to her military service, and was not further caused by ketones times one in urinalysis, diabetic symptomatology, skin and stomach problems (irritability), or any slow healing infections, during service. The November 2014 VA examiner further opined that it was less likely than not that the Veteran's diabetes mellitus, type I, was caused or aggravated by her service-connected psychiatric disorder, to include the Veteran's assertion that such disorder prevents her from properly taking care of herself and taking her diabetes medications. As rationale for the opinion, the examiner recorded that November 2014 VA treatment records revealed that the Veteran reported working as a substitute teacher. In this regard, the examiner explained that, in order for the Veteran to qualify as a substitute teacher, she would have to undergo a background check, and be physically and mentally stable. As such, the examiner determined that the Veteran's mood disorder was considered stable by the staff clinical psychologist. Consequently, she concluded that the Veteran's currently diagnosed diabetes type I was not caused or aggravated by her service-connected mood disorder, and does not prevent the Veteran from properly taking care of herself and taking her medications for her diabetes. As stated previously, the Board first denied the Veteran's claim in February 2015, primarily on the basis of the November 2014 VA examiner's opinion. However, the Court's Memorandum Decision found that the Board erred by relying on such opinion with respect to whether her diabetes mellitus, type I, was etiologically related to her psychiatric disorder as it was predicated on an inaccurate factual premise. Here, the Court found that the November 2014 VA treatment records indicated that the Veteran was not working as a substitute teacher, but rather, had a desire to "return to substitute teaching." Therefore, the Court determined that as a result of the November 2014 VA examiner's misreading of such VA treatment records, her medical opinion was based on an inaccurate premise and entitled to no probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Accordingly, pursuant to a November 2016 Board remand, an addendum opinion on such matter was obtained in December 2016. At such time, the examiner opined that it was less likely than not that the Veteran's diabetes mellitus, type I, was proximately due to or the result of her service-connected psychiatric disorder. In this regard, the examiner noted that the Veteran's current severity of her diabetes mellitus, type I, was not greater than the baseline. Here, the examiner recorded that the Veteran's HbA1c at the time of her diagnosis was 10.8%, and blood sugar levels were in the 700s. The examiner further recorded that the Veteran's most recent HbA1c of record was from April 2016, which indicated 9.4%. The examiner indicated that there was no evidence that the Veteran experienced worsening of her diabetes mellitus, type I, beyond natural progression, and the Veteran has had poor control since her diagnosis. As rationale for the opinion, the December 2016 VA examiner noted that she did not feel that the Veteran's mental health condition was so impaired that her self-care had been affected. In this regard, she indicated that the Veteran had demonstrated over the years a response to stress with complaints of nausea and vomiting, with some of this behavior being suggested in service; however, it was noted that her symptoms tended to resolve with periods where the Veteran was not involved in conflict. As an example, the examiner noted that the Veteran was symptom-free for a period of nine years after discharge from service. Additionally, she observed that the Veteran's gastrointestinal (GI) complaints became a prominent feature in 1997 when her disorder was reviewed and remained persistent for years later. The examiner noted that such pattern was suggestive of a somatoform disorder, but symptomatology persisted; as such, there was some evidence of a psychological component to the Veteran's complaints over the years. The examiner explained, however, that whether or not such was related to a service condition, which resolved for nine years, was questionable. In this regard, the examiner reported that it was possible that the Veteran did not have a separate GI or psychological condition, but rather, her symptoms were simply related to her metabolic abnormalities. The examiner further noted that she had difficulty connecting the Veteran's behavior in service, which appeared to be more related to maladaptive coping mechanisms that predated service at best, considering they manifested within a day of basic training. Furthermore, she indicated that the Veteran's only period of control of her diabetes was possibly in the first 3-4 years or so following her diagnosis. In this regard, the examiner noted that no HbA1c levels were available from such time period; however, results found in treatment records suggested that control was not as good as the Veteran indicated to her provider. The examiner further stated that such pattern was most consistent with noncompliance. Moreover, she determined that none of the mental health records she reviewed suggested that the Veteran had been so impaired by her mental health condition that her compliance was impaired. In this regard, the examiner explained that the Veteran lived alone, was able to perform all of her ADLS unassisted and secure employment at short intervals over the years, and had reported completing a Bachelor's degree. Further, records indicated that she was in law school. In addition, the examiner noted that a mental health examination had been performed in March 2015, which reflected that the Veteran reported that she "benefited greatly" from her ongoing treatment and the March 2015 examiner observed the same. The examiner further noted that, during such examination, the Veteran reported that her medications and treatment were "helpful and valuable." Consequently, the examiner found that such history was not consistent with someone who was unable to perform care related to a complicated medical problem. However, in rendering her opinion, the December 2016 VA examiner suggested that the Veteran's symptomatology and history would best be reviewed by a mental health provider to determine if her current mental health condition was severe enough to impair her compliance with prescribed therapy, and such mental health opinion would ultimately be necessary to decide the claim. Furthermore, the examiner did not consider the January 2001 private treatment record that noted an assessment of diabetes mellitus, type I, under poor control with severe stress due to psychosocial problems; the May 2002 private treatment record that reflected an assessment of diabetic ketoacidosis due to a crimped subcutaneous set in a person with marked psychosocial distress, or the December 2015 private treatment record reflecting a diagnosis of psychogenic vomiting. As such, the Board sought an expert medical opinion from VHA in November 2017 that addressed whether the Veteran's diabetes mellitus, type I, was caused or aggravated by her service-connected major depressive disorder with generalized anxiety disorder. In response, Dr. R.G., a VHA physician certified in neurology and psychiatry, opined that it was at least as likely as not that the Veteran's diabetes mellitus, type I, was not caused or aggravated by her service-connected major depressive disorder with generalized anxiety disorder. The VHA physician further opined that it was at least as likely as not that the Veteran met the criteria for a diagnosis of a somatoform disorder, which was pre-existing, and/or unrelated to her service-connected major depressive disorder with generalized anxiety disorder and/or diabetes mellitus, type I. As rationale for the opinions, the VHA physician reported that he agreed with the professional opinion of the December 2016 VA examiner regarding the Veteran's somatoform disorder in that such VA examination report was consistent with the clinical record of documentation over the years of the Veteran's coexistent diabetes mellitus, type I, and/or diabetic ketoacidosis and/or other unrelated metabolic abnormalities with "severe stress due to psychosocial problems" noted in 2001, "marked psychosocial distress" noted in 2002, and "psychogenic vomiting" noted in 2015. The VHA physician further reported that it was in his professional opinion that, within a reasonable degree of medical probability, the Veteran's somatoform disorder was connected to her pre-existing and/or unrelated emotional or characterological difficulties (personality style/personality disorder), which contributed to her physical complaints and her alleged claim. Additionally, the VHA physician indicated that he agreed with the December 2016 VA examiner's statement that the Veteran's behavior "appears to be more related to maladaptive coping mechanisms which predated service at best considering they manifested within a day of basic training." Here, the VHA physician explained that somatic symptom and somatization disorder referred to a somatoform disorder that reported physical symptoms that are fully, or partially, psychologically-based rather than organically-based. The VHA physician further explained that, in the instant case, psychosomatic behavior had been documented in the clinical record as individuals previously diagnosed with somatization disorder would usually meet DSM-5 criteria for somatic symptom disorder. The VHA physician noted that somatic symptom disorder implied that individuals had maladaptive thoughts, feelings, and behaviors that defined the disorder, in addition to their somatic symptoms as was evidenced in this case; symptoms were often highly distressing and resulted in significant functional impairment for an extended period, which was evidenced in this case; somatic symptom disorder implied preoccupation and/or anxiety/worry related to having one or more somatic symptoms, with or without a concurrent medical condition, which was evidenced in this case; and somatoform disorders generally had their onset before age 30 and had a female predominance as evidenced in this case. Furthermore, the VHA physician reported that the etiology of somatoform disorders included, but was not limited to as it related to this specific case, nausea and vomiting and/or abdominal pain symptoms as a substitute for unexpressed anger, and illness behaviors growing out of low self-esteem and as a means of enhancing social contact. The VHA physician further reported that borderline personality individuals usually had complex clinical presentations as seen in this case, and, in this specific case, diverse combinations over the years had been noted in the clinical record of anxiety, depression, impulsive behavior, an associated history of a chaotic family upbringing and suffering from childhood, as well as adult sexual trauma consistent characterological issues (personality style/disorder with borderline personality traits predominating), which was pre-existing and/or unrelated to military service or a service-connected disability. Here, the VHA physician noted that the Veteran's history included that, as described by the October 2017 VA examiner, she was "'snatched' at age four and a half and molested during this event" ... "She also stated that she was raped by her mother's boyfriend while growing up, and that her mother would not believe her when she told her what had happened." He further noted that the Veteran "described experiencing several traumatic events during childhood" ... "She stated that this impacted her social functioning and that she would 'always feel nervous or sick in social situations' as a child." In this regard, the VHA physician indicated that the Veteran was described in records with significant life-long and pre-existing and/or unrelated difficulties with interpersonal relationships, chronic anxiety, chronic depression, adjustment issues and associated history of somatic preoccupation. He further indicated that her history included identifiable psychosocial stressors of interpersonal and/or abusive relationships over the years with her husbands, adult daughter, adult son, sibling; associated history of cancer deaths in her family; and current financial difficulties, including being part of a homelessness program. The VHA physician reported that the Veteran's history also included her report that she was recently sexually assaulted by her professor at the college she was attending. The VHA physician concluded that the Veteran's family structure, interpersonal relationships, and characterological issues (personality style) had left her with a view of the world as hostile, a sense of low self-esteem, and a propensity to experience exaggerated somatic symptoms, including, but not limited to, abdominal pain, and nausea and vomiting complaints, consistent with a personality disorder and a somatoform disorder. He further concluded that a personality disorder was not caused or permanently worsened beyond normal progression by a service-connected disability. He also found that it was at least as likely as not that the Veteran's current diabetes mellitus, type I, was not caused or aggravated by her service-connected major depressive disorder with generalized anxiety disorder and it was at least as likely as not that the Veteran's pre-existing and/or unrelated emotional difficulties, regardless of cause, contributed to her perceptions of emotional and somatic complaints, and her alleged claim. The Board has carefully reconsidered the facts of this case, including the concerns raised in the Memorandum Decision. Ultimately, the appeal must again be denied because the preponderance of the evidence weighs against the Veteran's claim. In this regard, the Board places great probative weight on the November 2014 VA examiner's opinion that the Veteran's diabetes mellitus, type I, was not directly related to her service and the December 2017 VHA physician's opinion that such disorder was not caused or aggravated by her service-connected major depressive disorder with generalized anxiety disorder. In specific regard to the concerns raised by the Court with regard to the secondary aspect of the Veteran's claim, the Board notes that the December 2017 VHA physician did not rely on the Veteran's employment status as a substitute teacher in determining that her service-connected psychiatric disorder was not causing or aggravating her diabetes mellitus, type I. Furthermore, both the November 2014 and December 2017 opinions considered all of the pertinent evidence of record, and provided a detailed rationale for the conclusions reached, relying on and citing to the records reviewed. Moreover, the examiner offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. The Veteran has not submitted medical evidence to refute the November 2014/December 2017 opinions or otherwise diminish their probative weight. In this regard, the Board has considered the August 2007 statement offered by the Veteran's private treatment provider in which he indicated that, because of the Veteran's multiple medical problems, which he subsequently attributed to her diabetes, she has major depression with associated anxiety. However, such opinion indicates that the Veteran's psychiatric disorder is secondary to her diabetes, rather than vice versa. Therefore, as it does not address the relevant issue in question, it is not probative. The Board has also considered whether service connection for diabetes mellitus, type I, is warranted on a presumptive basis. However, the clinical evidence of record fails to show that the Veteran manifested diabetes mellitus, type I, to a degree of 10 percent within the one year following her active duty service discharge in August 1980. In this regard, the Board acknowledges that the Veteran alleged that she had gestational diabetes during pregnancy and was pregnant at the time of her separation from service. However, the Board finds that the Veteran's service treatment records do not reveal a diagnosis of gestational diabetes during service or upon her separation. Rather, such show that the Veteran was eight weeks pregnant at the time of her Report of Medical Examination for Separation and there is no in-service or post-service evidence that she had gestational diabetes with that pregnancy or that her current diagnosis of diabetes mellitus was due to gestational diabetes. In addition, she was pregnant in 1980 and was not diagnosed with diabetes mellitus type 1 until 1991. Moreover, as noted above, there is no evidence that the Veteran had diabetes during service. Instead, as interpreted by the November 2014 VA examiner, a medical professional, her July 1980 blood work reveled normal glucose and no further diabetic work-up was warranted at that time and, on her July 1980 separation examination, she denied any problems related to sugar or albumin in urine. Furthermore, the VA examiner determined that, while the Veteran's service treatment records reflect one occasion of small amount of ketones upon urinalysis, the records do not reflect skin and stomach problems (other than pregnancy or adjustment disorder), and no slow healing infections during service. Thus, the Board finds that any statements by the Veteran that she was treated for symptoms of diabetes mellitus in service to be not credible. Thus, the Board finds that the Veteran's statements that she had diabetes during service to not be credible as they are outweighed by the remainder of the evidence of record and were made under circumstances indicating bias or interest. See Caluza v. Brown, 7 Vet. App. 498 (1995). Furthermore, she has not alleged a continuity of diabetic symptomatology since service. Therefore, presumptive service connection for diabetes mellitus is not warranted. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309; Walker, supra. The Board notes that the Veteran has contended that her current diabetes mellitus, type I, is related to her service, or in the alternative, caused or aggravated by her service-connected major depressive disorder with generalized anxiety disorder. The Veteran, as a layperson, is certainly competent to report matters within her personal knowledge, such as the occurrence of an injury or event, or her own symptoms. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). However, in the instant case, the Board finds that the question regarding the potential relationship between diabetes mellitus, type I, and any instance of her service, or her service-connected major depressive disorder with generalized anxiety disorder, to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). In this regard, while the Veteran is competent to describe her current manifestations of her diabetes mellitus, type I, as well as her history of claimed symptoms and treatment for such disorder, the Board accords such statements regarding the etiology of such disorder little probative value as she is not competent to opine on such complex medical questions. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the diagnosis of diabetes mellitus, type I, requires the administration and interpretation of diagnostic testing. There is no indication that the Veteran possesses the requisite medical knowledge regarding such matters. Moreover, the Veteran has offered only conclusory statements regarding the relationship between her in-service complaints , and/or her service-connected major depressive disorder with generalized anxiety disorder, and her current diabetes mellitus, type I. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). Therefore, the Board affords the Veteran's statements as to the etiology of her diabetes mellitus, type I, no probative weight. Therefore, based on the foregoing, the Board finds that the Veteran's diabetes mellitus, type I, is not shown to be causally or etiologically related to any disease, injury, or incident during service, did not manifest within one year of the Veteran's service discharge, and is not caused or aggravated by her service-connected major depressive disorder with generalized anxiety disorder. As such, service connection for such disorder is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for service connection for diabetes mellitus, type I, that doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Bilateral Foot Disorder At her hearings and in documents of record, the Veteran alleged that her bilateral foot disorder is directly related to her military service, or in the alterative, secondary to her diabetes mellitus, type I. In this regard, she claimed that, while in service, she experienced the swelling of her feet and tendonitis. The Veteran also alleges that, due to her diabetes mellitus, type I, she suffered from neuropathy/nerve damage in her feet, to include numbness and tingling. Therefore, the Veteran alleges that service connection for such disorder is warranted. The Veteran's STRs reflect that, in December 1979, she complained of pain in the left foot for one week. It was noted that she complained of pain and an altered gait, and there was swelling and crepitus in the general ankle and Achilles region. X-ray revealed a normal left foot. Acute left ankle stress with Achilles tendinitis was diagnosed. She was given a gelocast for a week and crutches. A week later, such was removed as the Veteran complained it was too tight. At such time, it was observed that the swelling went down, there was no heat or edema, and the range of motion improved. It was noted that the Veteran had sporadic pain with palpation in that the pain seemed exaggerated when she was aware of the examination and negative when her attention was elsewhere. The assessment was left ankle within normal limits. Post-service treatment records do not reflect treatment for a bilateral foot disorder. Rather, VA treatment records show diagnoses of diabetic neuropathy and bunion on the right foot. An August 2007 private treatment record indicated that the Veteran was diagnosed with type 1 diabetes in 1991 and had been maintained on insulin since such time. It was further observed that she had brittle diabetes, due to poor control over many years, and developed complications, to include retinopathy, and peripheral and autonomic nervous system neuropathy. The Veteran was afforded a VA examination in February 2013. At such time, the examiner noted diagnoses of right and left ankle strains. In this regard, the Veteran reported that, as referable to her left ankle tendonitis, such had an onset in December 1979, at which time her ankle began to hurt, turn red, and the foot swelled as a result of wearing military boots. She further reported that her condition continued throughout military service and had gotten worse due to the fact that she was diabetic; that she is unable to wear high heel shoes due to the ankle pain and foot swelling; and that she experienced burning in her ankle and toes. Following an interview with the Veteran, a review of the record, and a physical examination, the examiner opined that the Veteran's left ankle condition was less likely than not incurred in or caused by her claimed in-service injury event, or illness. As rationale for the opinion, the examiner reported that the Veteran's current left ankle condition was a left ankle strain; that in December 1979, the Veteran was soft casted for Achilles tendonitis; and that also in December 1979, the Veteran was seen for left foot pain and evaluation revealed an acute left ankle strain with Achilles tendonitis. The examiner further reported that the Veteran was treated for left achilles tendonitis while serving in the military; however, the Veteran was suffering from a left ankle strain issue. Here, the examiner explained that such was based on the most recent X-ray and physical examination findings. The examiner further explained that the Veteran's two conditions were different and no link could be established between the two of them at that point in time. However, as the Board explained in its June 2014 remand, the February 2013 VA opinion was inadequate to decide the Veteran's claim. In this regard, the Board reported that the February 2013 VA examiner did not address the Veteran's right ankle disorder and, while the examiner documented the Veteran's continued complaints regarding her tendonitis symptoms, she opined that the currently diagnosed strain was not related to such complaints without providing any basis for such conclusion. Accordingly, the Board accords no probative weight to such opinion. Further, in light of such deficiencies, the Board remanded for an addendum opinion, which was rendered in November 2014. In this regard, at the Veteran's November 2014 VA examination, she was diagnosed with degenerative arthritis of both feet. The examiner noted that the Veteran reported that, while on active duty, she was seen and X-rayed on sick call for her left feet hurting in December 1979. She indicated that she continued to have foot problems as she is a diabetic. Following an interview with the Veteran, a review of the record, and a physical examination, the examiner opined that her bilateral foot disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In support of such opinion, the examiner noted that a review of the Veteran's service treatment records reveal sick call notes in December 1979 of a normal left foot x-ray and, at her July 1980 separation examination, she stated no to foot trouble, loss of toe, bone, joint deformity, arthritis, and bursitis. Furthermore, the examiner noted that the Veteran served from November 1979 to August 1980, and literature supports causes of degenerative joint disease as aging, obesity, and some diseases. The Board notes it appears that she inadvertently stated that that the Veteran's current foot condition, namely degenerative joint disease of the bilateral extremity, was "caused or incurred as a result of her active service"; however, her ultimate conclusion was that such was less likely related to her military service and could have been a natural progression of aging or uncontrolled diabetes. In this regard, it was also stated that literature supports diabetes as a cause of foot conditions. As stated previously, the Board first denied the Veteran's claim in February 2015, primarily on the basis of the November 2014 VA examiner's opinion. However, the Memorandum Decision found that the Board erred by relying on such opinion with respect to whether her diabetes mellitus, type I, was etiologically related to her psychiatric disorder as it was predicated on an inaccurate factual premise. Therefore, the Court further found that the Veteran's claim for a bilateral foot disorder must be remanded as well as it was inextricably intertwined with her claim for service connection for diabetes mellitus, type I. Accordingly, pursuant to the November 2016 Board remand, which sought an opinion that addressed whether the Veteran's bilateral foot disorder was caused or aggravated by her diabetes mellitus, type I, an addendum opinion was obtained in December 2016. In this regard, during the December 2016 VA examination, the Veteran reported that she was diagnosed with achilles tendonitis when she was in service. She further reported being seen more than once and was placed in a soft cast for a while. The Veteran denied any antecedent injury. Additionally, she indicated that her pain was not in the back of her heel as it was in the past; rather, she had a stinging pain in her toes, which felt numb at times and was burning in nature. She further indicated that she had not had treatment for her feet (neuropathy) since her discharge. Following an interview with the Veteran, a review of the record, and a physical examination, the November 2014 VA examiner reported that the Veteran did not have a current diagnosis of achilles tendonitis and there was no evidence of another foot-related condition secondary to diabetes mellitus, type I. In this regard, the examiner concluded that that the Veteran's bilateral foot disorder was less likely than not proximately due to or the result of her diabetes mellitus, type I. As rationale for the opinion, the examiner reported that the Veteran had not been diagnosed with a diabetes-related foot condition; rather, she had been noted to have degenerative changes in her feet, which were bilateral and most consistent with age-related changes. The examiner further reported that the Veteran had indicated that she did not have any current foot condition. In this regard, the examiner noted that the Veteran's claims in the past had been for a foot condition related to service; however, she was denied such in the past and there was no documented foot condition in her current medical records. The examiner further noted that, accordingly, there was no secondary foot condition related to diabetes. Furthermore, the examiner indicated that the Veteran refused a foot examination at that time so she was unable to document if she had any new diagnoses, but the Veteran denied such. The Board finds that the VA examiners' opinions rendered in November 2014 and December 2016 are entitled to great probative weight as such considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a detailed rationale, relying on and citing to the records reviewed. Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Furthermore, there is no contrary medical opinion of record. The Board has also considered whether service connection for a bilateral foot disorder is warranted on a presumptive basis. However, the clinical evidence of record fails to show that the Veteran manifested arthritis to a degree of 10 percent within the one year following her active duty service discharge in August 1980. Furthermore, her statements that she has experienced a continuity of symptomatology are not credible as they are inconsistent with the contemporaneous evidence of record. See Caluza, supra. In this regard, as noted previously, the Veteran's STRs reveal sick call notes in December 1979 of a normal left foot X-ray and, at her July 1980 separation examination, she reported "no" to foot trouble, loss of toe, bone, joint deformity, arthritis, and bursitis. Furthermore, while the Veteran's records reflect ongoing medical treatment for a variety of disabilities since the 1990's, such are entirely negative for non-neurological foot or ankle complaints until 2013, and a diagnosis of degenerative arthritis of both feet was not rendered until November 2014, almost 35 years after the Veteran's discharge from service. Moreover, it is clear that the Veteran had sought medical treatment on numerous occasions over the years and had complained of a variety of ailments; therefore, if she were having foot or ankle pain, it is reasonable to assume that she would have reported it while receiving medical care. Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (ascribing heightened credibility to statements made to clinicians for the purpose of treatment); See Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I. 2003) (noting that statements made for the purpose of diagnosis or treatment "are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care"). Therefore, the Board finds that the Veteran did not manifest arthritis, to include on the basis of continuity of symptomatology, within one year of her August 1980 discharge from service. As such, presumptive service connection is not warranted for a bilateral foot disorder. The Board notes that the Veteran has contended that her bilateral foot disorder is related to her service. The Veteran, as a layperson, is certainly competent to report matters within her personal knowledge, such as the occurrence of an injury or event, or her own symptoms. See Jandreau, supra; Buchanan, supra. However, in the instant case, the Board finds that the question regarding the potential relationship between a bilateral foot disorder, and any instance of her service, to be complex in nature. See Woehlaert, supra. In this regard, while the Veteran is competent to describe her current manifestations of her bilateral foot disorder as well as her history of claimed symptoms and treatment for such disorder, the Board accords such statements regarding the etiology of such disorder little probative value as she is not competent to opine on such complex medical questions. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones, supra. In this regard, the diagnosis of a foot or ankle disorder requires knowledge of the inner workings of the musculoskeletal system, to include the nature of the impact ill-fitting military boots have on the foot and ankle. There is no indication that the Veteran possesses the requisite medical knowledge regarding such matters. Moreover, the Veteran has offered only conclusory statements regarding the relationship between her in-service complaints and her bilateral foot disorder. See Waters, supra. Therefore, the Board affords the Veteran's statements as to the etiology of her bilateral foot disorder no probative weight. Finally, the Board notes that the Veteran has asserted that her bilateral foot disorder is secondary to her diabetes mellitus, type I. In this regard, VA regulations provide that a disability which is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected. However, as discussed above, the Veteran is not service-connected for diabetes mellitus, type I. As such, the Board finds that, under the law, she lacks legal grounds to establish entitlement to service connection for such disorder as secondary to her diabetes mellitus, type I. See Sabonis v. Brown, 6 Vet. App. 426 (1994). Insofar as service connection is not in effect for the disability claimed by the Veteran to have proximally caused her bilateral foot disorder, service connection on a secondary basis is not applicable under the law. As there is no legal entitlement, the claim of entitlement to service connection for a bilateral foot disorder as secondary to diabetes mellitus, type I, is without legal merit. Id. Therefore, based on the foregoing, the Board finds that the Veteran's bilateral foot disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service, arthritis did not manifest within one year of the Veteran's service discharge, and such is not caused or aggravated by a service-connected disability. As such, service connection for such disorder is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim for service connection for a bilateral foot disorder, that doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER Service connection for diabetes mellitus, type I, is denied. Service connection for a bilateral foot disorder is denied. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs