Citation Nr: 1824905 Decision Date: 04/24/18 Archive Date: 05/03/18 DOCKET NO. 07-32 584 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities, to include as secondary to service-connected onychomycosis and foot fungus. REPRESENTATION Veteran represented by: Daniel G. Krasnegor, Esq. WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD S. Delhauer, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1965 to June 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from February 2008 and December 2008 rating decisions by a Department of Veterans Affairs (VA) Regional Office. In May 2009, the Veteran testified in a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the evidentiary record. In a March 2011 decision, the Board denied entitlement to service connection for peripheral neuropathy of the lower extremities and entitlement to a total disability rating based on individual unemployability (TDIU). The Veteran appealed the Board's March 2011 decision to the United States Court of Appeals for Veterans Claims (Court). A November 2011 joint motion for remand (JMR) and Court Order set aside the Board's March 2011 decision, and remanded the claims to the Board for action consistent with the terms of the JMR. In April 2012 and May 2015, the Board remanded the claims for further development. In May 2017, the Veteran perfected an appeal as to entitlement to increased disability ratings for posttraumatic stress disorder (PTSD), onychomycosis and foot fungus, and pityriasis foreign folliculitis and lichen simplex chronicus on head, and entitlement to service connection for fungus of the back and for skin fungus of the bilateral hands. In December 2017, the Veteran perfected an appeal as to entitlement to service connection for fungus in the blood stream. However, the Board's review of the evidentiary record reveals that the Agency of Original Jurisdiction is still taking action on those issues, to include scheduling a hearing before the Board in appropriate docket order. As such, the Board will not accept jurisdiction over those issues at this time. Regarding the Veteran's appeal as to entitlement to TDIU, the Board notes that the representation of the Veteran's attorney is limited to the issues of entitlement to service connection for peripheral neuropathy of the lower extremities and entitlement to TDIU. However, the Veteran contends he is unable to obtain or maintain substantially gainful employment mainly due to the effects of his peripheral neuropathy and his service-connected PTSD. Accordingly, the Board finds the appeal for an increased rating for PTSD could have significant impact on the appeal for entitlement to TDIU, and therefore the issues are inextricably intertwined. Accordingly, the Board must defer decision on the matter of entitlement to TDIU. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). FINDING OF FACT The preponderance of the competent and credible evidence weighs against finding that the Veteran's current peripheral neuropathy of the bilateral lower extremities manifested within a year of his separation from active duty service, was incurred in or is otherwise related to his military service, or was caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for peripheral neuropathy of the bilateral lower extremities have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C. §§ 5103, 5103A, and implemented in part at 38 C.F.R. § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. First, the Veteran has submitted several statements contending that a copy of a Report of Medical History associated with the evidentiary record is fraudulent, and/or has been doctored to indicate he did not report foot trouble at the time of his separation from active duty service. See, e.g., January 2018 Veteran statement; September 2013 Veteran statement. However, the record the Veteran has submitted and contends is fraudulent appears to be a copy of his June 1965 Report of Medical History upon enlistment, not upon separation. That document is consistent with the Veteran's various reports that he did not have foot problems upon his entrance to service. As will be discussed below, the Board acknowledges that the April 1968 Report of Medical History upon the Veteran's separation from active duty service does reflect that the Veteran marked "Yes" regarding foot trouble. Further, the Veteran contends that at his installation during active duty service he saw a battery medic for his foot complaints, as a physician was not available unless he travelled 80 miles. See, e.g., May 2009 hearing testimony; April 2009 Veteran statement; January 2009 notice of disagreement. As will be discussed below, except for the April 1968 Report of Medical History, the Veteran's service treatment records do not indicate any complaints or treatment related to the Veteran's feet. In September 2002, the Veteran's complete service treatment records were forwarded to VA by the National Personnel Records Center. See VA Form 21-3101. Further, the Veteran has indicated he only has copies of his medical records from Fort Sheridan. See January 2009 notice of disagreement. The Veteran also testified before the Board in May 2009 that although he went to a medic about his feet, no one tried to treat him, give him any medication, and there was no diagnosis rendered. Accordingly, the Board finds the totality of the evidence of record does not indicate that there are outstanding treatment records from a battery medic to be obtained. In a March 2012 statement, the Veteran's representative contends that the August 2009 VA examiner's rationale was inadequate regarding an osteoarthritis opinion. This argument appears to have been included in error, as the Board finds the August 2009 VA examination report did not discuss arthritis, and the evidence of record does not indicate that the Veteran contends that he has arthritis in his feet or lower legs related to his active duty service. In a May 2013 statement, the Veteran's representative contends that the VA examiner who performed the May 2012 VA peripheral nerves examination, and who later also performed the January 2016 VA peripheral nerves examination, did not have adequate expertise to opine as to the etiology of the Veteran's peripheral neuropathy because the examiner is a family practice physician, not a neurologist, and peripheral neuropathy is a fairly complex condition. The Board may assume the competency of a VA medical examiner as long as, under 38 C.F.R. § 3.159(a)(1), the examiner is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Cox v. Nicholson, 20 Vet. App. 563 (2007). In a May 2013 email, the program manager of the Compensation and Pension (C&P) department of the Central Arkansas VA Healthcare System noted that peripheral nerve examinations do not require a specialist but may be conducted by a general medical provider, and opined that the May 2012 VA examiner was well-qualified to conduct such examinations by virtue of his training and expertise. Further, as will be discussed in detail below, in the January 2016 VA examination report the VA examiner stated that he reviewed the Veteran's case in detail with a C&P neurologist, who concurred with the VA examiner's opinion. Accordingly, the Board finds the VA examiner is competent to perform the May 2012 and January 2016 VA peripheral nerves examination, and to offer the January 2016 opinion. In a February 2013 statement, the Veteran's representative contends the May 2012 VA examiner's opinion regarding secondary service connection was inadequate because the examiner provided no authority to support his conclusion that typically skin conditions do not cause peripheral neuropathy. In a September 2014 statement, the Veteran's representative contends the May 2012 VA examiner's opinion regarding secondary service connection was inadequate because the examiner did not provide an adequate rationale for his negative opinion except to say that it was based on the reasons given for the opinion regarding athlete's foot in service, the examiner did not separate the onychomycosis from the foot fungus, or provide specific reasons for the lack of aggravation. However, the Board finds that in the May 2012 Medical Opinion Disability Benefits Questionnaire (DBQ), which will be discussed in detail below, the May 2012 VA examiner did provide a rationale based on medical literature and the nature of skin conditions. Further, in the January 2016 opinion, the VA examiner again provided an opinion regarding the service-connected skin condition, which the opinion indicates includes both the onychomycosis and the tinea pedis, supported by a detailed rationale including references to medical literature and a consultation with a C&P dermatology examiner as to his conclusion the Veteran's peripheral neuropathy would not be caused or aggravated by the service-connected onychomycosis and foot fungus. Accordingly, the Board finds the May 2012 and January 2016 VA examiner's opinions, considered together, are adequate upon which to base a decision regarding the theory of secondary service connection. D'Aries v. Peake, 22 Vet. App. 97 (2008). In August 2017 and March 2018 statements, the Veteran's representative contends the January 2016 VA examiner's opinion is inadequate and did not comply with the Board's remand instructions because the examiner provided an insufficient rationale as to why the Veteran's complaints or symptoms do not fit within the criteria of peripheral neuropathy symptoms. The representative contends the VA examiner did not address the Veteran's assertions that he has ongoing symptoms of peripheral neuropathy such as tingling and numbness since service, as directed by the Board in the May 2015 remand, and that the examiner did not really explain why the Veteran's reports that began in service are not chronic peripheral neuropathy symptoms. Further, the representative contends the VA examiner did not provide a sufficient rationale with regard to his conclusion that the types of pain for peripheral neuropathy and athlete's foot are different and therefore there would be no overlap in neurologic symptoms. The Court has held that "examination reports are adequate when, as a whole, they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion," even when the rationale does not explicitly "lay out the examiner's journey from the facts to a conclusion." Monzingo v Shinseki, 26 Vet. App. 97, 107 (2012) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012) (noting that the law imposes no reasons-or-bases requirement on examiners)). Here, although the January 2016 VA examiner did not specifically cite to a source such as a medical treatise to support his conclusion that the types of pain for peripheral neuropathy and athlete's foot are different and there would be no overlap in neurologic systems, the Board finds the January 2016 VA examiner indicated he had reviewed the evidentiary record, interviewed and examined the Veteran, consulted with a C&P dermatologist and neurologist, and discussed the potential overlap between symptoms of athlete's foot and symptoms of peripheral neuropathy as requested by the Board. The examiner specifically acknowledged and discussed what the medical evidence of record did and did not show in connection with the present claim, including consideration of the Veteran's contentions. There are no apparent inconsistencies or ambiguities in the examination report. The Board, in its own lay capacity, is not otherwise qualified to call into question the VA examiner's medical judgment, nor does the Board find any reason to do so. Monzingo, 26 Vet. App. at 107. Further, the Board finds that the January 2016 VA examination report indicates the VA examiner did acknowledge the Veteran's report of "foot trouble" upon separation from service, as well as his report of paresthesias, dysesthesias, and numbness of his feet beginning during and since active duty service. However, when read as a whole, the VA examiner's opinion indicates that the examiner found the Veteran's complaints at separation from service were related to a skin condition and not peripheral neuropathy, and the Veteran's reports of pain, numbness, and tingling in his feet beginning during and continuing since service were contradicted by other evidence of record, as will be discussed in detail below. Again, there are no apparent inconsistencies or ambiguities in the examination report, and the Board is not otherwise qualified to call into question the VA examiner's medical judgment, nor does the Board find any reason to do so. Monzingo, 26 Vet. App. at 107. Accordingly, as the January 2016 VA examination and opinion has sufficiently informed the Board of both the examiner's judgment on the medical questions at issue and the essential rationale for the opinions made, to include the questions posed by the Board in the May 2015 remand, the Board finds that the January 2016 VA examination and opinion is adequate upon which to base a decision. D'Aries v. Peake, 22 Vet. App. 97 (2008). Further, given the August 2009 VA neurological disorders examination, the May 2012 VA peripheral neuropathy examination report and opinion, the January 2016 VA examination report and opinion, and the readjudication of the claim in February 2017, October 2017, and November 2017, the Board finds there has been substantial compliance with its remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Neither the Veteran nor his representative has raised any other issues with the duty to notify or duty to assist regarding the claim of entitlement to service connection for peripheral neuropathy of the bilateral lower extremities. 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 duty to assist argument). Legal Criteria A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C. §§ 1110, 1131. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." 38 C.F.R. § 3.303(b). Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. Id. Service connection may be granted on a presumptive basis for certain chronic diseases, including organic diseases of the nervous system, if they are shown to be manifest to a degree of 10 percent or more within one year following a veteran's separation from active military service. 38 C.F.R. §§ 3.307, 3.309. The United States Court of Appeals for the Federal Circuit, however, has clarified that this notion of continuity of symptomatology since service under 38 C.F.R. § 3.303(b), which as mentioned is an alternative means of establishing the required nexus or linkage between current disability and service, only applies to conditions identified as chronic under 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established for any disability which is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996) (citing Gilbert, 1 Vet. App. at 54). Analysis Peripheral neuropathy of the bilateral lower extremities has been diagnosed during the appeal period. See, e.g., January 2016 VA peripheral nerves examination report; August 2009 VA EMG/NCS procedure results. First, the Board notes that while the Veteran's active duty service was during the Vietnam Era, the Veteran does not contend that he served in the Republic of Vietnam, or that his current peripheral neuropathy is related to exposure to an herbicide agent. Further, although the Veteran has reported being exposed to radiation from radars during service, the Veteran does not contend that his current peripheral neuropathy is related to any such radiation exposure. See May 2016 Veteran statement. The Veteran's service treatment records do not contain any complaints or notations of symptoms in the Veteran's feet, to include numbness, tingling, or pain. Upon separation, the Veteran's April 1968 Report of Medical History included the Veteran's notation of "Yes" for "foot trouble," but the Veteran marked "No" for neuritis. The explanation of pertinent data completed by the separation examiner listed athlete's foot of two-to-three months' duration. The April 1968 separation examination report indicates all body systems, including the Veteran's feet and neurologic systems, were found to be normal. The summary of defects and diagnoses indicates a normal examination other than widened inguinal rings. See also March 2006 VA general medical examination ("[V]eteran had bilateral inguinal ring dilation at the time of exams while in the military"). The Veteran contends his "foot trouble" reported on the April 1968 Report of Medical History indicated foot pain and not just a fungal condition. See, e.g., January 2009 notice of disagreement; March 12, 2008 Veteran statement; February 2008 Veteran statement. The Veteran contends he began experiencing symptoms of peripheral neuropathy, including pain, numbness, and tingling, before he was released from active duty, and the symptoms got worse as he got older. See, e.g., May 2009 hearing testimony; March 12, 2008 Veteran statement. The Veteran has indicated that he experienced these symptoms despite the fact his job in service was mostly a sitting position, and that he could only a medic was available at his installation for medical issues, not a physician. See, e.g., May 2009 hearing testimony; March 2009 Veteran statement; January 2009 notice of disagreement; March 20, 2008 Veteran statement. The Veteran further contends that at the time of his separation from service, no diagnosis was given for his foot pain, and the medical knowledge and/or technology may not have existed at that time to detect his neuropathy. See, e.g., January 2018 Veteran statement; December 2017 VA Form 9; March 2016 Veteran statements; May 2009 hearing testimony; March 2009 Veteran statement; January 2009 notice of disagreement; October 5, 2007 Veteran statement. The Veteran has reported being treated by a private physician, Dr. R.E.M., for his peripheral neuropathy shortly after active duty service. See January 2016 VA peripheral nerves examination report. However, the Veteran has indicated that treatment records from Dr. R.E.M. are not available. See, e.g., Veteran statement received in May 2017; February 2005 Board hearing testimony. A March 1995 treatment record for Dr. S.A., Jr. indicates the Veteran was seen for a general examination. The Veteran's neurologic examination revealed deep tendon reflexes 1+ and equal, generalized. The Veteran's sensory motor function was intact. In October 2002, a private neurologist, Dr. W.C., ordered nerve conduction studies and lower extremity circulation studies because the Veteran continued to report pain and numbness in his feet which was worse when he stood or tried to increase his activity. See also October 2002 Arkansas Vascular Laboratory request for noninvasive vascular study (symptoms include bilateral foot pain at rest and pain when walking). In a November 2002 treatment note, Dr. W.C. indicated the lower extremity NCV studies revealed a mild neuropathy of unclear etiology, and indicated the Veteran's left foot pain was most likely secondary to the neuropathy. Dr. W.C. prescribed a trial of Keppra for the Veteran's pain. A March 2003 treatment record from a private physician, Dr. J.A.C., appears to indicate that at that time the Veteran reported experiencing foot pain and fungus since his military service. Dr. J.A.C. referred the Veteran to a podiatrist to evaluate his nail infections. A March 2003 treatment note from podiatrist Dr. J.W.R. noted the Veteran's history regarding fungal infections of his feet, as well as his diagnosis of neuropathy in the feet. Upon examination, pin/needle paresthesias were indicated. Dr. J.W.R. recommended New Balance tennis shoes as the Veteran's current shoe gears was poorly supportive, and provided the Veteran with a certificate indicating he should be allowed to wear tennis shoes at work as needed. See also October 2007 VA Form 21-4142 (Veteran states Dr. R. recommended the New Balance shoes because of the constant pain in his feet). In December 2003, the Veteran established primary care with the Little Rock VA Medical Center (VAMC). During his initial visit, the primary care physician noted the Veteran's medical history included peripheral neuropathy, cause unknown. The physician noted neurologist Dr. W.C. had done nerve conduction studies, but that the neuropathy work-up was negative, so Dr. W.C. called it idiopathic. The physician substituted a prescription of amitriptyline for Keppra. In July 2009, the Board remanded the claim to afford the Veteran a VA examination to determine the nature and etiology of his peripheral neuropathy. The Board noted the Veteran's complaints of "foot trouble" and athlete's foot in April 1968, and stated that it is not inconceivable that some of the symptoms of athlete's foot, including burning, could somewhat overlap with those of peripheral neuropathy of the bilateral lower extremities. In August 2009, the Veteran was afforded a VA neurologic disorders examination. The VA examiner noted the 2002 treatment notes and diagnosis by Dr. W.C., and stated that no etiology had been found for the Veteran's polyneuropathy. The examiner noted the Veteran had recently had a variety of tests, all of which were within normal limits, and which had been normal in the past as well. The VA examiner noted the Veteran's report that he had noted pain in his feet as well as numbness for about 15 years, with pain mainly when standing but that could also be present sitting or lying down. Although the August 2009 VA examiner opined that he was unable to connect the Veteran's neuropathy to service, the Board previously found the VA examiner's opinion inadequate because the examiner did not opine as to whether the Veteran's current neuropathy is related to the Veteran's foot problems noted in service. See April 2012 Board remand; November 2011 JMR. In May 2012, the Veteran was afforded a VA peripheral nerves examination. The examiner noted the Veteran's report to the August 2009 VA examiner that his symptoms had started 15 years prior to that examination. In May 2012, the Veteran reported to the VA examiner that while in the military he noted intermittent symptoms described as pain in his feet following prolonged marching, which would resolve with rest. The Veteran further described paresthesias and dysesthesias of the feet over the past 15 years, and occasional numbness. The Veteran reported all of these symptoms would come and go, and standing triggered the symptoms. The Veteran also stated that he felt the burning of his feet was worse when he has tinea of the feet. Upon examination, the Veteran's peripheral neuropathy symptoms were bilateral moderate intermittent pain, mild paresthesias and/or dysesthesias, and mild numbness. Multiple nerves of the bilateral lower extremities were found to be affected. However, the VA examiner noted that full extensive lab work had previously been completed through the VAMC, without an etiology for the Veteran's peripheral neuropathy. The May 2012 VA examiner opined that it is less likely than not that the Veteran's neuropathy had its onset in the military. However, in the May 2015 remand the Board found the May 2012 VA examiner's opinion to be inadequate because the examiner did not properly address the contention that symptoms of athlete's foot can overlap with symptoms of peripheral neuropathy, or the Veteran's assertions that he has had ongoing symptoms of peripheral neuropathy since his service. The Board further noted that the Veteran's representative had submitted medical literature suggesting that pain from peripheral neuropathy may be intermittent, which contradicted part of the May 2012 VA examiner's rationale. See Cleveland Clinic Center for Continuing Education: Peripheral Neuropathy (submitted in September 2014); Mayo Clinic: Peripheral Neuropathy (submitted in September 2014); National Institute of Neurological Disorders and Stroke: Peripheral Neuropathy Fact Sheet (submitted in May 2013). Further, the Board indicated the examiner should address the contention that the Veteran's separation examination may not have been able to properly diagnose peripheral neuropathy because it is unclear that electronic diagnostic studies were performed. Regarding secondary service connection, the May 2012 VA examiner opined that tinea and other skin conditions do not typically cause peripheral neuropathy. See May 2012 VA peripheral nerves VA examination report. The examiner further stated that he was aware of no literature that would link tinea pedis or onychomycosis to neuropathy. The examiner explained that tinea pedis and onychomycosis are superficial infections of the skin that do not affect or alter nerve function. Therefore, the May 2012 VA examiner concluded that it is less likely as not that the Veteran's service-connected tinea pedis and onychomycosis caused or aggravated the Veteran's peripheral neuropathy. See May 2012 VA Medical Opinion DBQ. In January 2016, the Veteran was afforded another VA peripheral nerves examination, which was conducted by the same examiner as the May 2012 examination. The examiner noted the notation of "foot problems" at the Veteran's exit from service in 1968, diagnosed as being "athlete's foot." The Veteran reported the problem with his feet at the time of his exit from service was "foot fungus." At that time, the Veteran reported he could not remember if he had pain or peripheral neuropathy symptoms with his feet during service, but the Veteran reported having paresthesias, dysesthesias, and numbness of his feet since service. The Veteran reported the symptoms were intermittent but progressed over the years. Upon examination, the Veteran reported currently experiencing intermittent dysesthesias, paresthesias, and numbness in his feet and distal legs. The January 2016 VA examiner found the Veteran's peripheral neuropathy of the bilateral lower extremities is idiopathic, because despite an extensive workup in 2002, no causation has been found to explain the condition. The examiner noted the August 2009 VA examiner's determination that the neuropathy is idiopathic. The January 2016 VA examiner indicated that the evidentiary record including the Veteran's lay statements, VA treatment records, and private treatment records had been reviewed. The examiner opined that it is less likely than not the Veteran's peripheral neuropathy is related to his service, incurred during service, or had its onset during service. The January 2016 VA examiner noted that the evidence of record indicates the Veteran's peripheral neuropathy had its onset several years following the Veteran's separation from service, as records showed peripheral neuropathy complaints and a diagnosis in 2002 by the Veteran's treating neurologist. The examiner further noted the Veteran's report upon the 2009 VA examination that his peripheral neuropathy symptoms had their onset 15 years prior to that examination. The VA examiner opined that if there had been some insult in service to have caused the Veteran's peripheral neuropathy condition, the onset of symptoms and diagnosis would have been much sooner than this time period in regard to the usual course of peripheral neuropathy, and noted that there is no evidence of an injury or illness during service to have led to the Veteran's peripheral neuropathy condition long after his exit from service. The examiner concluded that this would prove from a medical standpoint that the onset was long after the Veteran's separation from service. The January 2016 VA examiner opined that it is less likely than not the Veteran's service-connected skin condition of the feet caused or aggravated his peripheral neuropathy. The examiner stated that per a dermatology C&P medical opinion, and a review of UpToDate, tinea pedis/onychomycosis have not been shown to cause peripheral neuropathy, and would not aggravate the peripheral neuropathy condition because the skin condition does not affect the peripheral nervous system from a general standpoint. Regarding the potential overlap of symptoms between athlete's foot and peripheral neuropathy, the January 2016 VA examiner opined that one usually gets acute pain with flares of tinea pedis/onychomycosis due to inflammation of the service-connected skin conditions rather than from chronic peripheral nerve involvement, but it does not cause typical chronic peripheral neuropathy symptoms. The examiner stated the types of pain are different, and therefore there would be no overlap of neurologic symptoms between neuropathy and the skin condition. The examiner explained skin symptoms are usually intermittent pain, but typically not neurologic in pattern as in chronic peripheral neuropathy, and typically do not lead to chronic neurologic problems. Neurologic symptoms from chronic peripheral neuropathy would include dysesthesia, paresthesias, numbness, and weakness and can be intermittent early on with an ascending pattern that is not seen in skin conditions. Skin symptoms would not lead to these symptoms as typical skin symptoms from onychomycosis/tinea pedis are not suggestive of peripheral neuropathy conditions, and would be mainly manifested with pain during flares but self-limiting with treatment and with usual resolution. The January 2016 VA examiner opined that the Veteran's medical record at exit, including the examination report, do not support a peripheral neuropathy condition, rather only a skin condition regarding the feet which usually is manifested as a chronic rash. The examiner acknowledged that both conditions can lead to intermittent symptoms, but usually different in description, other than both can cause pain, but usually self-limiting with non complicated skin conditions, with which the examiner noted the Veteran has been diagnosed. Further, the examiner noted that at the time of the separation examination, the Veteran denied any neuritis symptoms, which he stated would be indicative of a peripheral neuropathy condition if present. The examiner explained that as would be expected, individuals in the military will have foot pain from different causes. To be related to a chronic peripheral neuropathy condition, the examiner stated one would need to see evidence of paresthesias, dysesthesias, numbness, and leg weakness correlating with an abnormal neurologic examination. He found this is not shown during the Veteran's service, or shortly following his exit from service. Again the examiner noted the Veteran denied neurologic symptoms at exit, though he was noted to have skin problems with his feet, and that the neurologic examination was normal at the time of his exit from service. The examiner opined that in the absence of typical chronic peripheral neuropathy complaints, including no complaints of neuritis in the Veteran's reported history, the exit examination was adequate in light of the Veteran's peripheral neuropathy condition. The January 2016 VA examiner further noted that the Veteran was shown to have a normal neurologic examination by Dr. S.A., Jr. in 1987 [sic, 1995] which the examiner stated would be evidence that the Veteran's neurologic examination in service was adequate and concurrent with the civilian examination. The January 2016 VA examiner explained that idiopathic peripheral neuropathy typically is chronic and does not improve if the cause is unknown. Therefore, if the onset of the condition was during the Veteran's service, it would more like than not have progressively worsened as opposed to a symptom onset noted in 2002 with ongoing symptoms. The examiner opined that the fact the Veteran was noted to have a normal neurologic examination in 1987 [sic, 1995] as well as the fact he had a neurologic examination in 2002 confirming the onset of peripheral neuropathy symptoms would contradict the Veteran's statement of ongoing problems with peripheral neuropathy on an intermittent basis since his exit from service. The examiner further noted the medical literature submitted by the Veteran's representative was contradictory, in that one study noted peripheral neuropathy is typically chronic, and the study suggesting that occasionally peripheral neuropathy improves would be more in line with reversible, known causes of the peripheral neuropathy condition (which is not what the Veteran has given his condition is chronic), or following milder insult to the peripheral nerve that typically reverses and the nerve reverts back to normal following the acute nature of the condition, as opposed to progression of a chronic peripheral nerve condition. The examiner determined that because no treatable peripheral nerve condition was found, and the evidence suggests a chronic peripheral neuropathy condition that did not improve following onset, the Veteran's peripheral neuropathy condition would typically lead to chronic peripheral neuropathy with progressive symptoms over the years as opposed to a condition that would improve. Accordingly, the January 2016 VA examiner opined that all of the above considerations contradict the onset of a peripheral neuropathy condition in service as alleged by the Veteran, despite his claims and history. Finally, the January 2016 VA examiner indicated that he had reviewed the Veteran's case in detail with a neurology C&P examiner, who concurred with the January 2016 VA examiner's opinion. The Board affords great weight of probative value to the January 2016 VA examiner's opinion. The VA examiner reviewed the evidence of record, and considered the specific facts regarding the Veteran and his history, to include the noted "foot problems" at separation from service, and the Veteran's contentions of symptoms including pain, numbness, and tingling beginning during and continuing since service. The examiner addressed the potentially overlapping symptoms between the athlete's foot noted on the April 1968 Report of Medical History and peripheral neuropathy, and provided a sufficient rationale as to his conclusion that the symptoms of the conditions, including pain, can be differentiated, and the Veteran's reports were not consistent with an idiopathic chronic peripheral neuropathy condition, to include consideration of the medical literature submitted by the Veteran's representative. Further, the VA examiner provided a detailed rationale as to his finding that the Veteran's contentions regarding the onset of peripheral neuropathy symptoms in service, and continuation since his separation from service, are contradicted by the other evidence of record, to include consideration of the adequacy of the Veteran's separation examination. Finally, the examiner indicated a C&P neurologist reviewed the case, and concurred with his opinion. The Board also finds that the medical evidence of record does not contain a nexus opinion by a medical professional relating the Veteran's current peripheral neuropathy of the bilateral lower extremities to his active duty service. The Board has considered the lay evidence offered by the Veteran. This includes his statements in which he asserts his belief that his current peripheral neuropathy of the lower extremities began during service, was manifested within one year of his separation from service, or is otherwise related to his active duty service. See October 5, 2007 Veteran statement (regarding chronic disease contention). In general, lay witnesses are competent to testify as to their observations as well as opine on questions of diagnosis and etiology in some circumstances. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (lay witnesses are competent to testify as to their observations, but this testimony must be weighed against the other evidence of record); Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation). The Veteran is competent to describe the symptoms in his feet during and since his active duty service, to include pain, tingling, and numbness. However, the question of whether the Veteran's current peripheral neuropathy is related to the Veteran's reported symptoms during and following active duty service cannot be determined by mere observation alone. The Board finds that determining whether the Veteran's current peripheral neuropathy of the lower extremities is related to his active duty service is not within the realm of knowledge of a non-expert, given the lack of documented complaints regarding the Veteran's legs or feet during active duty service other than the notation of athlete's foot in April 1968, the lack of objective complaints of neurologic symptoms in the feet or legs until 2002, the indication of a skin condition of the feet and toenails beginning during and continuing since service which could account for some of the Veteran's symptoms, and the indication by the Veteran's treating physicians that a cause for the Veteran's peripheral neuropathy has not been found to date. As the evidence does not show that the Veteran has expertise in medical matters, the Board concludes that his nexus opinion in this regard is not competent evidence and therefore is not probative of whether his peripheral neuropathy of the lower extremities began during or is related to his active duty service. Accordingly, the Board finds the preponderance of competent and credible evidence weighs against finding that the Veteran's peripheral neuropathy of the lower extremities was incurred in service, manifested within one year following his separation from service, or is otherwise related to his active duty service. Therefore, service connection cannot be established on a presumptive basis or a direct basis. See 38 C.F.R. §§ 3.303; 3.307. Further, the Board finds that the preponderance of competent and credible evidence weighs against finding that the Veteran's current peripheral neuropathy of the lower extremities was caused or aggravated by a service-connected disability. The Board affords great weight of probative value to the May 2012 and January 2016 VA examiner's opinions. The VA examiner reviewed the evidence of record, and provided a detailed rationale as to why the Veteran's service-connected onychomycosis and tinea pedis do not cause or aggravate his peripheral neuropathy, to include addressing the Veteran's contentions regarding overlapping symptoms between his skin and conditions and peripheral neuropathy. The examiner also indicated he had consulted a dermatology C&P examiner. The Board finds that the medical evidence of record does not contain a nexus opinion by a medical professional that the Veteran's current peripheral neuropathy of the bilateral lower extremities is caused or aggravated by his service-connected onychomycosis and foot fungus. Again, the Board has considered the lay evidence offered by the Veteran. This includes his contentions regarding overlapping symptoms between his service-connected onychomycosis and foot fungus and his current peripheral neuropathy. In general, lay witnesses are competent to testify as to their observations as well as opine on questions of diagnosis and etiology in some circumstances. See Buchanan, 451 F.3d at 1336; Barr, 21 Vet. App. 303 (2007). Again, the Veteran is competent to report the symptoms he experiences in his feet. However, the question of whether the Veteran's current peripheral neuropathy of the lower extremities is caused or aggravated by his service-connected onychomycosis and foot fungus cannot be determined by mere observation alone. The Board finds that determining whether the Veteran's onychomycosis and/or tinea pedis affected the peripheral nerves in his feet in order to cause or aggravate his peripheral neuropathy is not within the realm of knowledge of a non-expert, given the complicated nature of the relationship between concurrent diagnoses, and that the diagnoses involve separate body systems (skin/nails and nerves). As the evidence does not show that the Veteran has expertise in medical matters, the Board concludes that his nexus opinion in this regard is not competent evidence and therefore is not probative of whether his peripheral neuropathy of the lower extremities was caused or aggravated by his service-connected onychomycosis and foot fungus. Accordingly, the Board finds the preponderance of competent and credible evidence weighs against finding that the Veteran's peripheral neuropathy of the bilateral lower extremities was caused or aggravated by a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). For the foregoing reasons, the Board must conclude that the preponderance of the evidence is against the claim of entitlement to service connection for peripheral neuropathy of the bilateral lower extremities. The benefit of the doubt doctrine is therefore not applicable, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). ORDER Entitlement to service connection for peripheral neuropathy of the bilateral lower extremities is denied. ____________________________________________ MICHAEL LANE Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs