Citation Nr: 19141908 Decision Date: 05/31/19 Archive Date: 05/31/19 DOCKET NO. 17-48 457 DATE: May 31, 2019 ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to service connection for a left knee disability. 3. Entitlement to service connection for a right knee disability. 4. Entitlement to service connection for a bilateral foot disability. 5. Entitlement to service connection for hypertension. 6. Entitlement to service connection for hemorrhoids. 7. Entitlement to service connection for acid reflux, also claimed as gastroesophageal reflux disease (GERD). 8. Entitlement to service connection for a stomach disability, claimed as a nervous stomach condition. 9. Entitlement to service connection for a right shoulder disability. ORDER Entitlement to service connection for a back disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a bilateral foot disability is denied. Entitlement to service connection for hypertension is denied. Entitlement to service connection for hemorrhoids is denied. Entitlement to service connection for acid reflux, also claimed as GERD is denied. Entitlement to service connection for a stomach disability, claimed as a nervous stomach condition is denied. Entitlement to service connection for a right shoulder disability is denied. FINDINGS OF FACT 1. A back disability was not manifest in service or within one year of separation, and is not otherwise attributable to service. 2. A left knee disability was not manifest in service or within one year of separation, and is not otherwise attributable to service. 3. A right knee disability was not manifest in service or within one year of separation, and is not otherwise attributable to service. 4. The Veteran was diagnosed with pes planus prior to entering active military service. 5. The Veteran’s pre-existing pes planus clearly and unmistakably did not increase in severity during service beyond its natural progression. 6. A bilateral foot disability was not manifest in service or within one year of separation, and is not otherwise attributable to service. 7. Hypertension was not manifest in service or within one year of separation, and is not otherwise attributable to service. 8. Hemorrhoids were not manifest in service. Hemorrhoids are not attributable to service. 9. Acid reflux, also claimed as GERD, was not manifest in service. Acid reflux, also claimed as GERD is not attributable to service. 10. A stomach disability was not manifest in service. A stomach disability is not attributable to service. 11. A right shoulder disability was not manifest in service or within one year of separation, and is not otherwise attributable to service. CONCLUSIONS OF LAW 1. A back disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 2. A left knee disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 3. A right knee disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 4. A bilateral foot disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 1153, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.307, 3.309 (2018). 5. Hypertension was not incurred in or aggravated by service, and cardiovascular-renal disease may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). 6. Hemorrhoids were not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 7. Acid reflux, also claimed as GERD, was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 8. A stomach disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1131, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2018). 9. A right shoulder disability was not incurred in or aggravated by service, and arthritis may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1985 to May 1988. This matter is before the Board of Veterans Appeals (Board) on appeal from a June 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§3.102, 3.156(a), 3.159, 3.326(a) (2018). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (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 [appellant] fails to raise them before the Board”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran’s claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board’s analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection To establish service connection a Veteran must generally show: “(1) the existence of a present disability; (2) 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.” Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). 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.” When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154 (a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. The Board, as fact finder, is obligated to, and fully justified in, determining whether lay evidence is credible in and of itself, i.e., because of possible bias, conflicting statements, etc. Id. Further, a negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 1. Entitlement to service connection for a back disability The Board incorporates its discussion from the sections above by reference. By way of background, the Service Treatment Records (STRs) include a January 1975 Report of Medical Examination from enlistment. It disclosed a clinically normal evaluation of the spine, other musculoskeletal system. A May 1988 Report of Medical Examination from separation disclosed a clinically normal evaluation of the spine, other musculoskeletal system. It shows a note of “lower back – 2 yrs” but nothing more in this regard. A September 1990 Report of Medical Examination from enlistment in the Army reserve is substantially the same. Decades later, the Veteran presented for care to the G. V. (Sonny) facility, part of the Jackson VA Medical Center (VAMC). A February 11, 2002 VA Primary Care Note from the PC Green Clinic shows, “back pain: began in military. uses ice, has gone to chiropractor. Never had surgery on his back. Takes muscle relaxer for this prn.” Next, the Veteran filed his claims for service connection for the issues currently on appeal, received by VA in October 2014. The Veteran was afforded an April 2015 VA back examination with medical opinion. The VA examiner reviewed the entire claims file, and performed an in-person examination of the Veteran. The VA examiner rendered a negative nexus opinion for the back. The physician rendered a detailed medical opinion: [The Veteran] has no examination in military or in summer camp that has any back abnormality found. there were no notes suggesting back injury or back problems on active duty. his exit exam in 05/1988 has a totally negative physical examination. in his handwriting on exam sheet there is a statement of ‘lower back 2 years’ and ‘knees 2 years’ and it is irregular that he would write on the examination form during examination; all that is available is electronic form; even if it were written in real-time in 05/1988, there is not found any substantiation. further, his 09/1990 enlistment in reserves history and physical clearly states NO recurrent back pain, and physical shows only flat feet and scars, otherwise normal physical. this is repeated in 12/1999 history and physical with (other than asymptomatic flat feet and scars) negative orthopaedics physical. [A] 10/2001 letter from dr [S.] sweet states has been seen with musculoskeletal pain in 09/2001 which was NOT during summer training camp [camp was during 10/2001], and her note does not specify back as source of musculoskeletal pain. in 02/2002 at his initial primary care at vamc he relates having had back pain and going to chiropractor, but did not have back pain at the time and had normal exam and no diagnosis for back. at his 11/2003 history he marked recurrent back pain and ‘currently in good health’; a handwritten note states has had some back pains over years, and states he hurt his back and hip in Korea when accidently ran into truck [no finding of back], but had a fully normal examination. in 01/2004 military profile states back pain and limited physical activities without any finding of an examination being done. on his 09/2011 Mississippi department of corrections pre-employment exam he lists back pain since 1996 which is after active duty, and has normal exam including spine, very specific for normal range of motion etc. [He] has back pain, but there is NO objective exam showing the back pain first began during active duty including during summer camp or during monthly reserve meetings. slight increase in sedimentation rate with normal anti-nuclear antibody and other rheumatologic tests is of uncertain significance though is less likely than not related to the back. current radiographs of the lumbosacral spine are completely normal and he has had no prior radiographs according to available records. the current thoracic radiograph shows very minimal thoracic spine kyphosis, and this is over 8 years since he stated he left all military service. the claimed condition of ‘back condition’ was significantly less likely than not (significantly less than 50 percent probability) incurred in or caused by the claimed in-service injury, events, or illness. The Veteran filed a timely Notice of Disagreement (NOD) in June 2016. Through several handwritten pages, the NOD in pertinent part gave an extensive reportage of the claims file and the Veteran’s general disagreement with the ultimate findings of VA. The June 2016 NOD shows in part, “I feel the entire process and decisions was unjust and unfair and I totally disagree with the decision and is filing this NOD saying so and if needed they may also serve as a appeal (sic) to the decisions made to deny my claim and I feel it is enough evidence and proof on file, along with the additional med. Information submitted today to approve said claim and awarded a fare (sic) percentage and decision. I feel this claim should be approved because my injuries, ailments and illnesses began or was aggravated during my military service time and duty over the years and continue to present day and will be into the future.” NOD p. 7. The Veteran generally requested that ongoing STRs and his lay statements be fully considered in reaching a decision. Next, the Veteran perfected his appeals in September 2017. In the September 2017 VA Form 9, the Veteran avers in part that he was injured in Korea in 1986 in the field. He hit his back very hard and lost his breath. He was treated by a medic. VA Form 9 p. 6. The Veteran and his representative’s April 2019 Informal Hearing Presentation (IHP) shows in the Statement of Facts, “The military occupational specialty, Bridge Crewmember provides bridge and rafting support for dry and wet gap crossing operations in tackling rough terrain in combat situations.” It concludes, “For the reasons set forth above, the appellant submits that the appropriate remedy for this appeal is reversal of the decision and a grant of the benefits sought.” The Veteran’s central theory of entitlement is that he was injured and also did several exercises in service, and this contributed to subsequent back disability that is now painful. See June 2016 NOD; September 2017 VA Form 9. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). More specifically, the Veteran is competent to report back pain. He is competent to report experiencing this following an injury in service. The Veteran is competent to relate what he has been told by a professional. He is competent to report when he began receiving treatment for the back, that he has arthritis, and when it was first identified by physicians. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran’s own lay opinions as to the diagnosis and cause of arthritis are not probative evidence, although the Veteran’s observed symptoms described may be useful to an expert in evaluating whether the Veteran has a disability and in determining the etiology thereof. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011). Because the record does not indicate that the Veteran has medical expertise, the Veteran’s lay opinion beyond a description of his symptoms is of limited probative value. The most probative evidence is the contemporaneous treatment records, including the STRs, and the opinion of the April 2015 VA examiner. First, the separation examination is clinically normal for the spine, other musculoskeletal system. Years after discharge from active duty service, in October 2001, the Veteran presented to the Family Health Care Clinic with complaints of musculoskeletal pain. Thus, the first documentation of the Veteran having back pain with possible disability was in 2001, though later he reported a history of back pain from in service when he presented to a VA facility in February 2002. Second, the Board also assigns significant probative weight to the detailed opinion of the April 2015 VA examiner. The physician reviewed the entire claims file, and provide detailed reasons and bases. The physician opined, “the claimed condition of ‘back condition’ was significantly less likely than not (significantly less than 50 percent probability) incurred in or caused by the claimed in-service injury, events, or illness.” The VA examiner again noted that the STRs and the VA examination from shortly after discharge are devoid of back pathology, and the Veteran denied recurrent back pain in his September 1990 Report of Medical History from enlistment in the Army reserves. The VA examiner further explained, “this is repeated in 12/1999 history and physical with (other than asymptomatic flat feet and scars) negative orthopaedics physical.” The VA physician noted the remote onset of back pathology “over 8 years since he stated he left all military service.” The Board assigns significant probative weight to the findings of the April 2015 VA examiner. Here, regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. A back disability was not manifest in service and is not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report back pain, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity, such as arthritis, pales in probative weight when compared to the objective medical evidence of record. Although there are some later accounts of back pain in service, the most probative evidence supports a finding that this was acute, transitory, and resolved. The Veteran’s theory of entitlement is largely based upon conclusory statements. The STRs from shortly after reported in-service injuries disclosed a clinically normal examination of the spine, other musculoskeletal system. Any inference that could be drawn from the notation of lower back – 2 yrs is outweighed by the comprehensive medical opinion of the VA examiner. Furthermore, we note that a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). In short, the most probative evidence is the clinically normal STRs upon discharge and April 2015 VA examination with medical opinion. The Board acknowledges Veteran’s contentions, including in the VA Form 9, however the April 2015 VA examination report considered the Veterans own extensive subjective impressions in rendering a definitely negative nexus opinion. There is no doubt to resolve. Consequently, service connection for a back disability is not warranted. 2. Entitlement to service connection for a left knee disability 3. Entitlement to service connection for a right knee disability The Board incorporates its discussion from the sections above by reference. By way of background, the Veteran’s January 1985 Report of Medical Examination from enlistment disclosed a clinically normal evaluation of the lower extremities. The May 1988 Report of Medical Examination disclosed a clinically normal evaluation of the lower extremities. It shows a note of “knees – 2 yrs” but nothing more in this regard. A September 1990 Report of Medical Examination from enlistment in the Army reserve is substantially the same. A related September 1990 Report of Medical History shows that the Veteran has undergone various treatment related to the knees, but with no residuals. However, the Veteran denied “Trick” or locked knee. Decades later, the Veteran presented for care to the G. V. (Sonny) facility. A February 11, 2002 VA Primary Care Note from the PC Green Clinic shows that the Veteran reported pain in the knees. Later treatment records from that same day show, “pt to pc green for follow up visit c/o chronic left leg knee x 5yrs2yrs., feet and back pain x 2 yrs. pain med taken staflex with good results, cold compresses applied to sore area and knee brace to left knee constantly.” Additional VA and private treatment records are substantially the same. The Veteran was afforded an April 2015 VA bilateral knee examination with medical opinion. The VA examiner reviewed the entire claims file, and performed an in-person examination of the Veteran. The VA examiner rendered a negative nexus opinion for the back. The physician rendered a detailed medical opinion: [H]is exit exam in 05/1988 has a totally negative physical examination. in his handwriting on exam sheet there is a statement of ‘lower back 2 years’ and ‘knees 2 years’ and it is irregular that he would write on the examination form during examination; all that is available is electronic form; even if it were written in real-time in 05/1988, there is not found any substantiation. he had normal knee exam. further, his 09/1990 enlistment in reserves history and physical clearly states NO knee problems, with history of fracture left knee ninth grade basketball injury to ‘knee cap’ with closed reduction, no residuals. physical shows only flat feet and scars, otherwise normal physical. this is repeated in 12/1999 history and physical with (other than asymptomatic flat feet and scars) negative orthopaedics physical. [A] 10/2001 letter from [Dr. S.] sweet states has been seen with musculoskeletal pain in 09/2001 which was NOT during summer training camp [camp was during 10/2001], and her note does not specify knee as source of musculoskeletal pain though it is likely that the knee(s) were referenced as she noted he was seen in 09/2001 due to musculoskeletal pain after running 2.5 miles, and was advised to refrain from running. in 02/2002 at initial primary care vamc he had no knee complaints. at his 11/2003 history he marked knee problems and ‘currently in good health’; a handwritten note states has had injured his knees during a physical training test that may have been in 2001 at fort mccoy [note summer camp was in 10/2001 and no health care notes show any knee problems there], but had a fully normal examination. in 01/2004 military profile states knee pain and limited physical activities without any finding of an examination being done. in 07/2005 at Mississippi emergency associates he gave history of left knee painful and swollen for 2 weeks without injury; left knee radiograph by formal report was negative; and he was diagnosed as left knee pain probably osteoarthritis and given a knee brace. as there was no follow-on note, and no finding of magnetic resonance image left knee, the knee clearly improved. on his 09/2011 Mississippi department of corrections pre-employment exam he lists the pre-military fracture, and has NO complaints found related to knee, ankle, or foot. he has normal exam of all extremities including range of motion. there is no mention of any knee, ankle, or foot problems in any other note. [S]light increase in sedimentation rate with normal anti-nuclear antibody and other rheumatologic tests is of uncertain significance though is less likely than not related to the knees. current radiographs show minimal osteoarthritis both knees, age-appropriate, and first noted over 7 years after he left all military service. bilateral bipartite patellae with history of only left knee probably patellar fracture suggests may not have had pre-military patellar fracture, but did have pre-military injury to left knee. bipartite patellae more likely than not developmental anomaly, though less likely could have been unilateral right bipartite patella and fracture left patella without union. the claimed condition of ‘knee condition’ was significantly less likely than not (significantly less than 50 percent probability) incurred in or caused by the claimed in-service injury, events, or illness. The Veteran contends that he is entitled to service connection for right and left knee disabilities. See June 2016 NOD; September 2017 VA Form 9. The Veteran is competent to provide evidence of that which he experiences, and to relate what he has been told by a professional. The most probative evidence is the contemporaneous treatment records, including the STRs, and the opinion of the April 2015 VA examiner. First, the separation examination is clinically normal for the lower extremities. Years after discharge from active duty service, in October 2001 the Veteran presented to a VA facility for treatment related to the left knee, with a history of this pain for 5 years. Thus, the first documentation of the Veteran having left knee pain with possible disability was in 2001. He reported the onset many decades after separation from active duty service. Second, the Board also assigns significant probative weight to the detailed opinion of the April 2015 VA examiner. The physician reviewed the entire claims file, and provide detailed reasons and bases. The physician discussed the Veteran’s history of knee injury, and ultimately opined, “the claimed condition of ‘knee condition’ was significantly less likely than not (significantly less than 50 percent probability) incurred in or caused by the claimed in-service injury, events, or illness.” The VA physician noted that even construing notations in the STRs in favor of the Veteran, there was no evidence of knee disability at discharge. This finding was bolstered by evidence from after separation showing a clinically normal evaluation of the knees. The Board assigns significant probative weight to the findings of the April 2015 VA examiner. Here, regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. A right and/or left knee disability was not manifest in service and is not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report knee pain, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity, such as arthritis, pales in probative weight when compared to the objective medical evidence of record. Although there are some later accounts of knee pain and a history of possible injury, the most probative evidence supports a finding that this was acute, transitory, and resolved. The Veteran’s theory of entitlement is largely based upon conclusory statements. The STRs from shortly after his period of active duty service disclosed a clinically normal examination of the lower extremities, which is consistent with other STRs and treatment records. The notation of knees – 2 yrs pales in comparison to the medical evidence and comprehensive opinion of the VA examiner. Furthermore, we note that a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson, supra. In short, the most probative evidence is the clinically normal STRs upon discharge and April 2015 VA examination with medical opinion. The Board acknowledges Veteran’s contentions, however the April 2015 VA examination report considered the Veterans medical history in rendering a definitely negative nexus opinion. There is no doubt to resolve. Consequently, service connection for a right and/or left knee disability is not warranted. 4. Entitlement to service connection for a bilateral foot disability The Board incorporates its discussion from the sections above by reference. A preexisting injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 C.F.R. § 3.306. When the Veteran is presumed sound at entrance, the burden then falls on the Government to rebut the presumption of soundness by clear and unmistakable evidence that the Veteran’s disability was both preexisting and not aggravated by service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Bagby v. Derwinski, 1 Vet. App. 225, 227 (1991). The U.S. Court of Appeals for Veterans Claims (Court) in Horn v. Shinseki, explained that even when there is clear and unmistakable evidence of preexistence, the claimant need not produce any evidence of aggravation in order to prevail under the aggravation prong of the presumption of soundness. Rather, the burden is on VA to establish by clear and unmistakable evidence that it did not or that any increase was due to the natural progress of the disease. 25 Vet. App. 231, 235 (2012). On the other hand, where a disorder is noted on service entrance or a Veteran is otherwise not presumed sound on entrance, 38 U.S.C. § 1153 applies. In such claims, the evidence of record must simply show that there was an increase in disability during service to trigger the presumption of aggravation. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). “If the presumption of aggravation under section 1153 arises, the burden then shifts to the government to show a lack of aggravation by establishing ‘that the increase in disability is due to the natural progress of the disease.” Wagner, 370 F.3d at 1096 (citing 38 U.S.C. § 1153). This requires the government show by clear and unmistakable evidence that any increase in disability was due to the natural progress of the condition. Cotant v. Principi, 17 Vet. App. 116, 130-32 (2003); Horn v. Shinseki, 25 Vet. App. at 235 (2012) (“Once the Veteran establishes worsening, the burden shifts to the Secretary to show by clear and unmistakable evidence that the worsening of the condition was due to the natural progress of the disease.”); see also 38 C.F.R. § 3.306 (b). Clear and unmistakable evidence means that the evidence “cannot be misinterpreted and misunderstood, i.e., it is undebatable.” Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009) (quoting Yanerson v. West, 12 Vet. App. 254, 258-59 (1999)). The clear-and-unmistakable-evidence standard is an “onerous” one. Laposky v. Brown, 4 Vet. App. 331, 334 (1993) (citing Akins v. Derwinski, 1 Vet. App. 228, 232 (1991)); see also Yanerson, 12 Vet. App. at 263 (Nebeker, C.J., concurring in part and dissenting in part) (“[O]nly an inference that is iron clad and copper riveted can be ‘unmistakable.’“). By way of background, the Veteran’s January 1985 Report of Medical Examination from enlistment shows an impression of asymptomatic pes planus second degree. The May 1988 Report of Medical Examination disclosed a clinically normal evaluation of the feet. A September 1990 Report of Medical Examination from enlistment in the Army reserve shows an impression of moderate, asymptotic pes planus. Later, a December 1999 Report of Medical Examination shows an impression of pes planus that was mild and asymptomatic. In this case, STRs note pes planus upon entry. In that case section 1153 applies and the burden falls on the Veteran to establish aggravation. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the presumption of aggravation under section 1153 arises, the burden shifts to the government to show a lack of aggravation by establishing “that the increase in disability is due to the natural progress of the disease.” 38 U.S.C. § 1153; see also 38 C.F.R. § 3.306; Jensen, 19 F.3d at 1417; Wagner, 370 F. 3d at 1096. In deciding a claim based on aggravation, after the presence of a preexisting condition has been established, the Board must determine (1) whether there has been any measured worsening of the condition during service, and (2) whether this constitutes an increase in disability. Browder v. Brown, 5 Vet. App. 268, 271 (1993); Hensley v. Brown, 5 Vet. App. 155, 163 (1993). Over two decades after discharge, a February 11, 2002 VA Primary Care Note from the PC Green Clinic shows feet and back pain for two years. Additional VA and private treatment records are substantially the same. Over a decade after that, the Veteran was afforded an April 2015 VA bilateral foot examination with medical opinion. The VA examiner reviewed the entire claims file, and performed an in-person examination of the Veteran. First, the VA examiner opined, “The condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness.” The VA examiner reasoned: [H]as bunions now, unlikely existed during military time. hallux valgus currently, no finding of existence during military and less likely than not to have existed 8 years ago. slight increase in sedimentation rate with normal anti-nuclear antibody and other rheumatologic tests is of uncertain significance though is less likely than not related to the feet. Regarding flat feet, the VA examiner also opined, “The claimed condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury or illness.” The physician explained, “flat feet confirmed, existed pre-military; no finding of significant worsening beyond natural progression.” The Veteran contends that he is entitled to service connection for a bilateral foot disability. See June 2016 NOD; September 2017 VA Form 9. The Veteran is competent to provide evidence of that which he experiences, and to relate what he has been told by a professional. The most probative evidence is the contemporaneous treatment records, including the STRs, and the opinion of the April 2015 VA examiner. First, the separation examination is clinically normal for the feet. After discharge from active duty service, in September 1990, the entrance examination for the reserves showed an impression of flat feet. Second, the Board also assigns significant probative weight to the detailed opinion of the April 2015 VA examiner. The physician reviewed the entire claims file, and provide detailed reasons and bases. The physician discussed the Veteran’s history of flat feet, and ultimately rendered a negative nexus opinion for direct service connection. The VA examiner found that there was no foot pathology (other than the flat feet, discussed separately) in service. Regarding flat feet, the physician opined, “The claimed condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury or illness.” The physician reasoned, “flat feet confirmed, existed pre-military; no finding of significant worsening beyond natural progression.” The Board assigns significant probative weight to the findings of the April 2015 VA examiner. Here, regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. A bilateral disability (other than flat feet) was not manifest in service and is not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report foot pain, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity, such as arthritis, pales in probative weight when compared to the objective medical evidence of record. Although there are some later accounts of foot pain and a history of pes planus (discussed separately below), the most probative evidence supports a finding that this was acute, transitory, and resolved. The STRs from separation disclosed a clinically normal examination of the feet, which is consistent with other STRs and treatment records from enlistment in the reserves. We note that a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson, supra. Next, regarding aggravation, the Board notes that the Veteran was diagnosed with pes planus before active service. Taken together, the STRs and VA examination paint a clear and unmistakable picture that the Veteran’s pes planus did not worsen during service. While the January 1985 enlistment examination showed flat feet, they were asymptomatic. They were not referenced in the May 1988 Report of Medical History from separation. Only two years later, in September 1990, they are also listed, but as asymptomatic. In reviewing the evidence, the Board notes that a Report of Medical History from separation is not of record. Additionally, the April 2015 VA physician opined that Veteran’s pes planus was not aggravated or increased in severity from his service. Indeed, the evidence clearly and unmistakably supports this conclusion. The Board finds this medical opinion to be highly probative. In short, the evidence of record reveals that the Veteran’s post-service statements and actions, and the April 2015 VA examination with medical opinion, established to a clear and unmistakable level that the Veteran’s pes planus was not incurred in or aggravated by service. Any perceived increase in disability during service was due to the natural progress of the disease. See 38 U.S.C. § 1153; 38 C.F.R. § 3.306. There is no probative evidence to the contrary. The Board acknowledges Veteran’s contentions, however, the April 2015 VA examination report considered the Veterans medical history in rendering a definitely negative nexus opinion for all theories of entitlement. There is no doubt to resolve. Consequently, service connection for a bilateral foot disability is not warranted. 5. Entitlement to service connection for hypertension The Board incorporates its discussion from the sections above by reference. By way of background, the May 1988 Report of Medical Examination disclosed a clinically normal evaluation of the heart and vascular system. A September 1990 Report of Medical Examination from enlistment in the Army reserve is substantially the same, without any signs or symptoms suggestive of hypertension. In the related Report of Medical History, the Veteran wrote that his health was “good” and that his current medications were “none.” He denied high or low blood pressure. Later, a December 1999 Report of Medical Examination shows a notation of a history of hypertension and treatment. Decades later, the Veteran was afforded an April 2015 VA examination. The physician reviewed the claims file, and thoroughly considered the Veteran’s lay medical history. In part, the VA examination shows, “However, the Veteran states that he was first treated for HTN by a private practitioner at a local urgent care clinic, the MEA Clinic in Clinton, Mississippi, in the ‘early nineties.’ A Report of Medical Examination (ROME) from May 1988 records a blood pressure (BP) of 115/65 mm Hg at the Veteran’s then weight of 142 pounds, along with an unremarkable cardiovascular examination.” After examining the Veteran, the physician opined, “Veteran with benign, essential HTN, addressed with tolerated combination drug therapy, which was NOT incurred on active duty and which was NOT due to, the result of, NOR permanently aggravated by military duty, deployment exposure, or other service connected conditions, and which would NOT hinder employability.” This was a negative nexus opinion encompassing all possible theories of entitlement. Additional VA and private treatment records are substantially the same. The April 2019 IHP shows in the Statement of Facts that there were persistent elevated blood pressure readings in the STRs. The IHP does not contain a more detailed discussion of this possible theory of entitlement or supporting medical opinions. Nevertheless, we have proceeded with evaluating the claim based upon the governing laws and evidence of record. The Veteran is competent to report when he began receiving treatment for hypertension, and when it was identified by medical treatment providers. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The most probative evidence is the contemporaneous treatment records, including the STRs. First, the STRs are clinically normal for the heart and vascular system. Several years later, STRs from a period of reserve duty show notations of hypertension with an onset on or before December 1999. The Board assigns substantial probative weight to the contemporaneous treatment records. Importantly, the April 2015 VA physician reviewed the claims file and the Veteran’s lay history. The Veteran’s own lay history put the onset of hypertension sometime in the 1990s. The VA physician reviewed in-service laboratory findings. The VA examiner did acknowledge the later onset of hypertension. The VA examiner identified benign hypertension, and rendered negative nexus opinions for all theories of entitlement. The Board assigns substantial probative weight to these findings. Regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. Hypertension was not manifest in service and is not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report being diagnosed with hypertension, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity, such as cardiovascular-renal disease, pales in probative weight when compared to the objective medical evidence of record. The Board has relied upon the opinion of the April 2015 VA examiner in considering in-service blood pressure readings, and is not relying on its own judgment in this specific regard. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). When considering the presumptive period of one year, the Board is sympathic to the Veteran’s circumstances. However, the most probative evidence establishes a remote onset of hypertension several years after discharge. The Board has considered multiple theories of entitlement, to include direct service connection and presumptive service connection. There is no doubt to resolve. Regardless of the theory, service connection for hypertension is not warranted. 6. Entitlement to service connection for hemorrhoids The Board incorporates its discussion from the sections above by reference. By way of background, the May 1988 Report of Medical Examination disclosed a clinically normal evaluation of the anus and rectum, G-U system, and abdomen and viscera. A September 1990 Report of Medical Examination from enlistment in the Army reserve is substantially the same. A December 23, 2008 Operative Report from Dr. R. K. J. at St. Dominic Ambulatory Surgery Center shows in part, “He reports symptoms of diarrhea bright red blood per rectum constipation tenesmus and anal pain which began approximately 3 months and has become worse.” It then shows, “ The diagnostic workup to date has included a colonoscopy. The colonoscopy was performed by [T.] P. [M.] MD on 04 07 2008 and it demonstrated internal hemorrhoids in the anus.” The ultimate impression was “Normal colonoscopy except for small internal hemorrhoids.” A related follow-up report shows in part, “No hemorrhoids or fissures present. Perineum is normal. Digital rectal exam showed no external hemorrhoids. Good rectal tone. No substantial internal hemorrhoid.” The Veteran reported that any pain had resolved. Years later, the Veteran was afforded an April 2015 VA examination. The VA examiner reviewed the claims file, and noted the onset of internal or external hemorrhoids in 2008. The VA examiner remarked, “Self-report of surgical intervention of thrombosed external hemorrhoid, unverified; internal hemorrhoid noted on colonoscopy, addressed with diet and non-prescription therapy, uncomplicated, which would not hinder employability. NO hemorrhoidal condition incurred on active duty, NOR due to, or the result of, military duty or deployment exposures.” This negative nexus opinion implicitly encompasses all theories of entitlement. Additional VA and private treatment records are substantially the same. The Veteran contends that he is entitled to service connection for hemorrhoids. The Board assigns substantial probative weight to the contemporaneous treatment records, including the STRs, and the findings of the August 2015 VA examiner. First, the STRs disclosed a clinically normal evaluation of the anus and rectum and G-U system upon separation. Hemorrhoids were identified by private treatment providers in 2008, roughly two decades after discharge. Next, the April 2015 VA physician reviewed the claims file, examined the Veteran, and rendered a negative nexus opinion. We assign substantial probative weight to the findings of the April 2015 VA examiner. The April 2019 IHP contains no specific argument related to hemorrhoids, and is notably devoid of references to evidence of an onset in service or nexus. Here, hemorrhoids were not manifest in service and are not attributable to service. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report bleeding, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity pales in probative weight when compared to the objective medical evidence of record. A negative inference may also be drawn from the absence of complaints or treatment for an extended period. Maxson, supra. In short, the most probative evidence in the clinically normal STRs and April 2015 VA medical opinion establishes the remote onset of hemorrhoids several years after discharge. There is no doubt to resolve. Consequently, service connection for a hemorrhoids is not warranted. 7. Entitlement to service connection for acid reflux, also claimed as gastroesophageal reflux disease (GERD) 8. Entitlement to service connection for a stomach disability, claimed as a nervous stomach condition The Board incorporates its discussion from the sections above by reference. By way of background, the May 1988 Report of Medical Examination disclosed a clinically normal evaluation of the lungs and chest, endocrine system, and G-U system. A September 1990 Report of Medical Examination from enlistment in the Army reserve is substantially the same. In the related Report of Medical History, the Veteran denied frequent indigestion, and stomach, liver, or intestinal trouble. Over a decade later, a Report of Medical History is included in the STRs from the Veteran’s period of reserve duty, received on December 15, 2003, and dated November 19, 2003. In the Report, the Veteran wrote, “Have had stomach problems over the years, it is my guess that having been in the field a lot on training and eating many MRE’s, cold food and simply eating in the Field Environment has caused me stomach and digestion problems. While in the Active Army, went to sick call on occasions for stomach upsets, and was dehydrated before [and] after Field Exercises.” Years later, the Veteran was afforded an April 2015 VA examination. It shows the onset of GERD in the early 1990s per the Veteran’s report. The VA examiner elicited a further lay history from the Veteran: The Veteran reports he was placed on a prescription antacid by a private practitioner in the “early nineties,” around the time he was diagnosed with hypertension. These primary records are not contained in the Claims-file. The Veteran reports lower endoscopy, but can not recall an EGD or UGI series. He states his symptoms were initially heartburn with “gas, a queasy feeling...diarrhea,” which he had addressed by eating “bland food” and using OTC products, prior to being prescribed daily drug therapy. . . . . The Veteran denies a history of ulcer or upper GI bleed, odynophagia, dysphagia, regurgitation, or weight loss due to UGI distress. The Veteran’s STRs do not document episodes of acute care for gastrointestinal distress. Upon physical examination, symptoms of GERD included persistently recurrent epigastric distress, pyrosis, reflux, and nausea. Next, the VA physician provided three enumerated remarks: 1. Unverified claim of a chronic gastrointestinal disorder with onset during active duty service. 2. Current diagnoses of GERD and IBS, addressed with a tolerated and effective prescription PPI, with self-report of onset in the 1990s, NOT due to, NOR the result of military duty or deployment exposures, which would NOT hinder employability. 3. The Veteran’s (reported) acute indigestion and stomach upset due to the composition of military meals, or the setting in which they were ingested, is LESS likely than not responsible for the later development of the chronic GI conditions diagnosed by non-military practitioners. These negative nexus opinions implicitly encompass all theories of entitlement related to the stomach and GERD. VA treatment records show impressions of and treatment for GERD, and are substantially the same. Next, the June 2016 NOD shows in part, “I had an additional apptm (sic) directed by Dr. [R.] about my gastroesophageal reflux disease (GERD) and stomach issues at JAC Radio UGI/BS/SBFT clinic. The Doctor and staff did the exam and saw my gastroesophageal reflux disease (GERD) be activated by their tests and said I have it and they would be reporting it.” NOD p. 6. Later, in the September 2017 VA Form 9, the Veteran avers in part, “I specifically remembered going to the Doctor at Ft. Stewart, GA for various stomach problems, it was sick call, during morning hrs (sic) at the local clinic on base, not a large hospital, one for stomach dehydration issues, from a field problem and another for stomach problems, upset stomach on base 1987-1988.” VA Form 9 p. 5. The Veteran contends that he is entitled to service connection for GERD and a stomach disability, claimed as nervous stomach. The Veteran’s central theory of entitlement is that stomach issues, later diagnosed in part as GERD, began in service, possibly relating to eating MREs. He was treated in local clinics on base. The Veteran is competent to report experiencing symptoms of acid reflux and an upset stomach in service. The Veteran is competent to relate what he has been told by a professional. He is competent to report when he began receiving treatment for GERD, and when it was first identified by treatment providers. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The most probative evidence is the contemporaneous treatment records, including the STRs, and the opinion of the April 2015 VA examiner. First, the separation examination is clinically normal for the lungs and chest, endocrine system, and G-U system. In the 1990 Report of Medical History from two years after separation from active duty, the Veteran denied frequent indigestion, and stomach, liver, or intestinal trouble. The Veteran’s own lay history relates the onset of GERD as sometime in the early 1990s. Second, the Board also assigns significant probative weight to the opinions of the April 2015 VA examiner. The physician reviewed the entire claims file, interviewed the Veteran, and provide detailed reasons and bases. The physician ultimately rendered all negative nexus opinions for GERD and any claimed stomach disability. In part, the VA examiner opined, “Current diagnoses of GERD and IBS, addressed with a tolerated and effective prescription PPI, with self-report of onset in the 1990s, NOT due to, NOR the result of military duty or deployment exposures, which would NOT hinder employability.” We assign substantial probative weight to the findings of the April 2015 VA examiner. Here, the weight of the evidence shows that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. GERD and a stomach disability were not manifest in service and are not attributable to service. In addition, the Board finds that while competent to report what he has been told by his physician and to report experiencing upset stomach in service, his own lay history relates GERD to years after separation. There is also no probative evidence of a stomach disability in service. Further, the Veteran’s theory of entitlement is largely based upon conclusory statements regarding a stomach disability in 1987 to 1988. The STRs from shortly after this time period disclosed a clinically normal examination of the lungs and chest, endocrine system, and G-U system, later echoed in subsequent STRs. In short, the most probative evidence is the clinically normal STRs upon discharge and April 2015 VA examination with medical opinion. The most probative evidence establishes a remote onset of stomach and esophageal pathology several years after discharge. The weight of the evidence is against the claims. There is no doubt to resolve. Consequently, service connection for GERD and a stomach disability is not warranted. Entitlement to service connection for a right shoulder disability The Board incorporates its discussion from the sections above by reference. By way of background, the May 1988 Report of Medical Examination disclosed a clinically normal evaluation of the upper extremities. A September 1990 Report of Medical Examination from enlistment in the Army reserves is substantially the same. In the related Report of Medical History, the Veteran denied lameness and painful or “trick” shoulder or elbow. Years later, a February 11, 2002 VA treatment record shows in part, “pt c/o nodule to right shoulder x 2month.” A June 25, 2014 VA Primary Care Follow Up Note from the G.V. (Sonny) Montgomery VAMC shows that the Veteran was last week one week ago for right shoulder pain. He reportedly had x-rays. The Veteran reported that he was told that he has arthritis and a pinched nerve in the shoulder. Later VA treatment records from October 2014 show a reported tingling and stinging sensation in the right arm and shoulder. The April 2015 VA examination related to the back shows an ongoing medical history of right shoulder pathology in the record. The April 2019 IHP contains no specific argument related to the right shoulder. Nevertheless, we have proceeded with evaluating the claim based upon the governing laws and evidence of record. The Veteran is competent to report a painful right shoulder, and when he began receiving related treatment. The most probative evidence is the contemporaneous treatment records, including the STRs. First, the STRs are clinically normal for the upper extremities. Two years after discharge, in 1990, the Veteran denied lameness and painful or “trick” shoulder or elbow. We assign substantial probative weight to these records. VA treatment records from 2014, over two decades after separation, show that the Veteran presented with right shoulder pain. The Veteran reported that he was told that he had arthritis. Here, regarding direct or presumptive service connection, we find that the Veteran did not have the characteristic manifestations necessary to identify the disease entity in service. A right shoulder disability was not manifest in service and is not attributable to service. The STRs and Veteran’s medical history itself provided no suggestion of an in-service occurrence indicative of a right shoulder disability. There is no probative evidence to the contrary. In addition, the Board finds that while competent to report what he has been told by his physician and to report being diagnosed with arthritis, the Veteran’s own lay opinion regarding identifying a potential chronic disease entity pales in probative weight when compared to the objective medical evidence of record. The Board is sympathic to the Veteran’s circumstances. However, the most probative evidence establishes a remote onset of any right shoulder disability several decades after discharge. Additionally, the Board observes that the Veteran has not been provided with a VA examination and request for a medical opinion on the issue of direct causation for the contended right shoulder disability. The evidence does not establish that the Veteran suffered “an event, injury or disease in service,” so it is not necessary to obtain a VA medical opinion with regard to etiology. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Court has held that VA is not required to provide a medical examination when there is not credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Additionally, a conclusory generalized lay statement that service event or illness caused the claimant’s purported disability is insufficient to require the Secretary to provide an examination. See Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). The Board has considered multiple theories of entitlement, to include direct service connection and presumptive service connection. Regardless of the theory, entitlement to service connection for a right shoulder disability is not warranted. There is no doubt to resolve. Neither the Veteran nor his representative has raised any other issues, nor have any other issues been reasonably raised by the record. See Doucette v. Shulkin, 28 Vet. App. 366 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). (Continued on the next page.) In reaching these conclusions, the Board finds that the preponderance of the evidence is against the claims. As such, the benefit of the doubt rule is not for application, and the claims must be denied. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Michael Pappas Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Bodi, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.