Citation Nr: 20034471 Decision Date: 05/18/20 Archive Date: 05/18/20 DOCKET NO. 10-15 462 DATE: May 18, 2020 ORDER Service connection for degenerative joint disease of the right shoulder is denied. Service connection for degenerative joint disease of the lumbar spine is denied. Service connection for degenerative joint disease of the knees is denied. Service connection for essential hypertension is denied. FINDINGS OF FACT 1. Degenerative joint disease of the right shoulder was not manifest in service or within the one-year presumptive period following service. Degenerative joint disease of the right shoulder is not attributable to service. 2. Degenerative joint disease of the right shoulder is not caused or aggravated by a service-connected disease or injury. 3. Degenerative joint disease of the lumbar spine was not manifest in service or within the one-year presumptive period following service. Degenerative joint disease of the lumbar spine is not attributable to service. 4. Degenerative joint disease of the lumbar spine is not caused or aggravated by a service-connected disease or injury. 5. Degenerative joint disease of the knees was not manifest in service or within the one-year presumptive period following service. Degenerative joint disease of the knees is not attributable to service. 6. Degenerative joint disease of the knees is not caused or aggravated by a service-connected disease or injury. 7. Hypertension was not manifest in service or within the one-year presumptive period following service. Hypertension is not attributable to service. 8. Hypertension is not caused or aggravated by a service-connected disease or injury. CONCLUSIONS OF LAW 1. The criteria for service connection for degenerative joint disease of the right shoulder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for degenerative joint disease of the lumbar spine have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for degenerative joint disease of the knees have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 4. The criteria for service connection for essential hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1954 to September 1954. The Veteran had service with the Texas National Guard from August 1949 to August 1952. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2009 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that in June 2019, the Veteran asked to withdraw the appeal. Subsequently, the RO sent him a letter requesting him to confirm which issues he wished to withdraw. The Veteran’s July 2019 response was unclear and seemed to indicate that he wished to continue the appeal. In its May 2020 appeal brief, the Veteran’s representative requested the continued adjudication of the appeal. Consequently, the Board does not dismiss the appeal and adjudicates it on its merits. Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Although the Veteran’s representative cites certain duties VA has to assist the Veteran, the representative does not assert state that a breach of these duties has occurred. Service Connection 1. Service connection for degenerative joint disease of the right shoulder. The Veteran asserts that his degenerative joint disease of the right shoulder is due to rheumatic fever contracted in service or is due to his service-connected rheumatic heart disorder, as shown in his February 2010 claim form. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of degenerative joint disease (DJD) of the right shoulder, and evidence shows that the Veteran contracted rheumatic fever in service, the preponderance of the evidence weighs against finding that the Veteran’s shoulder DJD began during service or is otherwise related to an in-service injury, event, or disease. In service, multiple joint arthralgias were reported and the Veteran’s diagnosis of rheumatic fever was then discovered. Treatment records show that the joint symptoms promptly subsided upon treatment of rheumatic fever. He was subsequently discharged after a medical board review because of his residuals of rheumatic heart disease. Private treatment records show the Veteran was not diagnosed with any type of arthritis until April 1971, when he was diagnosed with gouty arthritis. Even if gouty arthritis were connected with DJD, this did not occur until over a decade after separation from service. A December 1970 statement by the Veteran is the first indication of a shoulder disability. Furthermore, a November 1983 X-ray as part of a VA examination found no shoulder joint changes. A January 2005 X-ray after a recent motor vehicle accident showed degenerative changes in the rotator cuff. A February 1955 VA orthopedic examination report discussed the Veteran’s rheumatic fever treatment and course. The report stated that the Veteran had multiple migratory joint stiffness and pain and was treated for rheumatic fever. The report further stated that since the treatment, the Veteran has had no complaint of joint pain. The examiner then explained that rheumatic fever arthralgia is transient, and that joint pain is only a symptom of the underlying pathology that attacks other organs. The examiner concluded that there were no joint residuals of rheumatic fever. VA examiners in February 2016 and October 2018 provided opinions regarding the Veteran’s DJD and the rheumatic fever and rheumatic heart disease. Taken together, the February 2016 and October 2018 VA examiners’ opinions establish that the Veteran’s shoulder DJD is not at least as likely as not related to an in-service rheumatic fever or rheumatic heart disease. The February 2016 VA examiner opined that the Veteran’s degenerative joint disease of the shoulder is likely due to the natural aging process. The examiner found that there is no pathophysiologic relationship between rheumatic fever/rheumatic heart disease and osteoarthritis. The October 2018 VA examiner added that there is no reputable medical literature connecting the two. The examiners’ combined opinions are probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran did not report continuous symptoms of shoulder pain, or any other shoulder symptoms, since service. The Veteran believes his right shoulder DJD is related to an in-service rheumatic fever, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the etiology and pathophysiology of internal organ systems. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiners’ opinions. The evidence as evaluated above does not show that right shoulder DJD had its onset in service or within the one-year presumptive period following service. Accordingly, the chronic disease presumption for arthritis does not apply. 38 C.F.R. §§ 3.307, 3.309. The Board also considers the Veteran’s theory that service connection is warranted on a secondary basis. In other words, the Board considers the Veteran’s contention that his shoulder DJD is secondary to the service-connected rheumatic heart disease. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or was aggravated beyond its natural progress by service-connected rheumatic heart disease as residuals of rheumatic fever. The Board concludes that the preponderance of the evidence is against finding that the Veteran’s right shoulder DJD is proximately due to or the result of, or aggravated beyond its natural progression by service-connected rheumatic heart disease. 38 U.S.C. §§ 1110, 1131; Allen, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). Again, the Board turns to the February 2016 and October 2018 VA medical opinions. These opinions show that the Veteran’s rheumatic heart disease did not cause the right shoulder DJD because age was the likely cause and there is no pathophysiologic relationship between the two. Moreover, the October 2018 VA medical opinion further stated that there is no mechanism of action for cause or aggravation of degenerative arthritis of the bilateral shoulder joints by rheumatic heart disease. The Board acknowledges that the October 2018 examiner stated that it was less likely than not that his shoulder DJD was “permanently aggravated” beyond its natural progression. Aggravation by a service connected disability is not required to be permanent for secondary service connection to be established. Ward v. Wilkie, 31 Vet. App. 233 (2019). However, reading the entirety of the opinion, it is clear that the examiner opined that no aggravation at all occurred, neither permanent nor temporary. The examiner stated, “[t]here is no mechanism of action for cause or aggravation of bilateral osteoarthritis of the … shoulder AC joints by rheumatic fever/rheumatic heart disease.” Because the examiner found that no aggravation occurred at all, his use of the word “permanent” does not render the opinion inadequate or less probative. These opinions are probative evidence because they are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Additionally, the October 2018 medical opinion provided substantial compliance with the March 2018 Board remand because it addresses etiology of the disability and whether the disability was aggravated by the service-connected rheumatic heart disease and the physician provided a persuasive rationale. Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran believes his right shoulder DJD is proximately due to or the result of/aggravated beyond its natural progression by rheumatic heart disease. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the etiology and pathophysiology of internal organ systems. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, 492 F.3d at 1377; see also Kahana, 24. Vet. App. 428. Consequently, the Board gives more probative weight to the VA examiners’ opinions. Finally, although in a November 2009 statement, the Veteran asserted that DJD of the shoulder was present when he entered service in 1953, the Board finds the more probative evidence shows that it was not. Specifically, the January 1954 enlistment examination showed normal upper extremities and did not note symptoms related to the shoulder. Thus, the Veteran is presumed to be in sound condition at entrance to service. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304 (b); see also 38 U.S.C. § 1111; Crowe v. Brown, 7 Vet. App. 238, 245 (1994). As the preponderance of the evidence is against the claim, the Board finds service connection is not warranted. 2. Service connection for degenerative joint disease of the lumbar spine. The Veteran asserts that his degenerative joint disease of the spine is due to rheumatic fever contracted in service or is due to his service-connected rheumatic heart disorder, as shown in his February 2010 claim form. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of degenerative joint disease (DJD) of the spine, and evidence shows that the Veteran contracted rheumatic fever in service, there is no competent evidence establishing that the Veteran’s spine DJD began during service or is otherwise related to an in-service injury, event, or disease. In service, multiple joint arthralgias were reported and the Veteran’s diagnosis of rheumatic fever was then discovered. Treatment records show that the joint symptoms promptly subsided upon treatment of rheumatic fever. He was subsequently discharged after a medical board review because of his residuals of rheumatic heart disease. Private treatment records show the Veteran was not diagnosed with any type of arthritis until April 1971, when he was diagnosed with gouty arthritis. Even if gouty arthritis were connected with DJD, this did not occur until over a decade after separation from service. In February 1980, X-rays show degenerative changes in the lumbar spine were present. Again, this was over a decade after separation from service. A February 1955 VA orthopedic examination report discussed the Veteran’s rheumatic fever treatment and course. The report stated that the Veteran had multiple migratory joint stiffness and pain and was treated for rheumatic fever. The report further stated that since the treatment, the Veteran has had no complaint of joint pain. The examiner then explained that rheumatic fever arthralgia is transient, and that joint pain is only a symptom of the underlying pathology that attacks other organs. The examiner concluded that there were no joint residuals of rheumatic fever. No current VA medical examination and medical opinion was rendered in this case. Although a medical opinion was requested, the record shows it was cancelled at the request of the Veteran around the time the Veteran was attempting to withdraw the claim. In the May 2020 appellate brief, the Veteran’s representative asked the case to be adjudicated based on the evidence now of record. Accordingly, while a medical opinion was not rendered, the Board interprets the Veteran’s actions and the representative’s statements as a waiver of the right to have a medical opinion rendered. Accordingly, there was substantial compliance with the Board remand directives requesting a medical opinion. Stegall, 11 Vet. App. at 271. The Veteran did not report symptoms of low back pain or low back symptoms continuously since service. The Veteran believes his low back DJD is related to an in-service rheumatic fever, however, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the etiology and pathophysiology of internal organ systems. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, 492 F.3d at 1377 n.4; see also Kahana, 24. Vet. App. 428. His lay assertion is not competent evidence. Consequently, a link to service has not been established. As no medical opinion was rendered, there is no competent evidence of a link between the low back disability and rheumatic fever or rheumatic heart disease. A claimant has the responsibility to present and support a claim for benefits under laws administered by the VA, 38 U.S.C. § 5107(a). While VA has a duty to assist the Veteran in substantiating his claim, that duty is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190 (1991). The evidence as evaluated above does not show that the low back DJD had its onset in service or within the one-year presumptive period following service. Accordingly, the chronic disease presumption for arthritis does not apply. 38 C.F.R. §§ 3.307, 3.309. The Board also considers the Veteran’s theory that service connection is warranted on a secondary basis. In other words, the Board considers the Veteran’s contention that his low back DJD is secondary to the rheumatic heart disease. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or was aggravated beyond its natural progress by service-connected rheumatic fever. 38 C.F.R. § 3.310. The Board concludes that there is no competent evidence establishing that the Veteran’s low back DJD is proximately due to or the result of, or aggravated beyond its natural progression by service-connected rheumatic heart disease. 38 U.S.C. §§ 1110, 1131; Allen, 7 Vet. App. 439; 38 C.F.R. § 3.310(a). A September 2006 VA medical opinion was rendered. It found that spinal stenosis was not likely secondary to the Veteran’s rheumatic heart disease, finding that there is no physiological relationship between rheumatic heart disease and the development of spinal stenosis. Again, there was no current medical opinion. The Board turns to the discussion above for the lack of VA medical opinion. As such, there is no medical evidence of aggravation. The Veteran believes his low back DJD is proximately due to or the result of/aggravated beyond its natural progression by rheumatic heart disease. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the etiology and pathophysiology of internal organ systems. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, 492 F.3d at 1377; see also Kahana, 24. Vet. App. 428. His opinion is not competent evidence. Consequently, the Board gives more probative weight to the VA examiners’ opinions. Finally, although in a November 2009 statement, the Veteran asserted that DJD of the spine was present when he entered service in 1953 and that he was born with a crooked spine, the Board finds the more probative evidence shows that it was not. Specifically, the January 1954 enlistment examination showed normal spine and did not note symptoms related to the spine on the entrance examination. Thus, the Veteran is presumed to be in sound condition at entrance to service. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304 (b); see also 38 U.S.C. § 1111; Crowe , 7 Vet. App. at 245. As competent evidence of a link between service or service-connected disability and the current disability is not present, the Board finds service connection is not warranted. 3. Service connection for degenerative joint disease of the knees. The Veteran asserts that his degenerative joint disease of the knees is due to rheumatic fever contracted in service or is due to his service-connected rheumatic heart disorder, as shown in his February 2010 claim form. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of degenerative joint disease (DJD) of the knees, and evidence shows that the Veteran contracted rheumatic fever in service, the preponderance of the evidence weighs against finding that the Veteran’s knee DJD began during service or is otherwise related to an in-service injury, event, or disease. In service, multiple joint arthralgias, including knee arthralgia, were reported and the Veteran’s diagnosis of rheumatic fever was then discovered. Treatment records show that the joint symptoms promptly subsided upon treatment of rheumatic fever. He was subsequently discharged after a medical board review because of his residuals of rheumatic heart disease. Private treatment records show the Veteran was not diagnosed with any type of arthritis until April 1971, when he was diagnosed with gouty arthritis. Even if gouty arthritis were connected with DJD, this did not occur until over a decade after separation from service. A November 1983 VA examination diagnosed the Veteran with bilateral chondromalacia of the patellas. Again, these are over a decade after service. A diagnosis of DJD of the knees was not made until May 2009. A February 1955 VA orthopedic examination report discussed the Veteran’s rheumatic fever treatment and course. The report stated that the Veteran had multiple migratory joint stiffness and pain and was treated for rheumatic fever. The report further stated that since the treatment, the Veteran has had no complaint of joint pain. The examiner then explained that rheumatic fever arthralgia is transient, and that joint pain is only a symptom of the underlying pathology that attacks other organs. The examiner concluded that there were no joint residuals of rheumatic fever. VA examiners in February 2016 and October 2018 provided opinions regarding the Veteran’s DJD and the rheumatic fever and rheumatic heart disease. Taken together, the February 2016 and October 2018 VA examiners’ opinions establish that the Veteran’s knee DJD is not at least as likely as not related to an in-service rheumatic fever or rheumatic heart disease. The February 2016 VA examiner opined that the Veteran’s degenerative joint disease of the knees is likely due to the natural aging process. The examiner found that there is no pathophysiologic relationship between rheumatic fever or rheumatic heart disease with the knee DJD. The October 2018 VA examiner added that there is no reputable medical literature connecting the two. The examiners’ combined opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran did not report symptoms of knee pain or other knee symptoms continuously since service. The Veteran believes his knee DJD is related to an in-service rheumatic fever, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the etiology and pathophysiology of internal organ systems. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, 492 F.3d at 1377 n.4; see also Kahana, 24. Vet. App. 428. Consequently, the Board gives more probative weight to the VA examiners’ opinions. The evidence as evaluated above does not show that knee DJD had its onset in service or within the one-year presumptive period following service. Accordingly, the chronic disease presumption for arthritis does not apply. 38 C.F.R. §§ 3.307, 3.309. The Board also considers the Veteran’s theory that service connection is warranted on a secondary basis. In other words, the Board considers the Veteran’s contention that his knee DJD is secondary to the rheumatic heart disease. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or was aggravated beyond its natural progress by service-connected rheumatic fever. The Board concludes that the preponderance of the evidence is against finding that the Veteran’s knee DJD is proximately due to or the result of, or aggravated beyond its natural progression by service-connected rheumatic heart disease. 38 U.S.C. §§ 1110, 1131; Allen, 7 Vet. App. 439; 38 C.F.R. § 3.310(a). Again, the Board turns to the February 2016 and October 2018 VA medical opinions. These opinions show that the Veteran’s rheumatic heart disease did not cause the knee DJD because age was the likely cause and there is no pathophysiologic relationship between the two. Moreover, the October 2018 VA medical opinion further stated that there is no mechanism of action for cause or aggravation of degenerative arthritis of the knee joints by rheumatic heart disease. The Board acknowledges that the October 2018 examiner stated that it was less likely than not that his knee DJD was “permanently aggravated” beyond its natural progression. However, reading the entirety of the opinion as a whole, it is clear that the examiner opined that no aggravation at all occurred, neither permanent nor temporary. The examiner stated, “[t]here is no mechanism of action for cause or aggravation of bilateral osteoarthritis of the knees… by rheumatic fever/rheumatic heart disease.” Because the examiner found that no aggravation occurred at all, his use of the word “permanent” does not render the opinion inadequate or less probative. These opinions are probative evidence because they are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Additionally, the October 2018 medical opinion provide substantial compliance with the March 2018 Board remand because it addresses etiology of the disability and whether the disability was aggravated by the service-connected heart disease. Stegall, 11 Vet. App. at 271. The Veteran believes his knee DJD is proximately due to or the result of/aggravated beyond its natural progression by rheumatic heart disease. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the etiology and pathophysiology of internal organ systems. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, 492 F.3d at 1377 n.4; see also Kahana, 24. Vet. App. 428. Consequently, the Board gives more probative weight to the VA examiners’ opinions. Finally, although in a November 2009 statement, the Veteran asserted that DJD of the knees was present when he entered service in 1953, the Board finds the more probative evidence shows that it was not. Specifically, the January 1954 enlistment examination showed normal lower extremities and did not note symptoms related to the right shoulder. Thus, the Veteran is presumed to be in sound condition at entrance to service. 38 U.S.C. § 1111 (2012); 38 C.F.R. § 3.304 (b); see also 38 U.S.C. § 1111; Crowe, 7 Vet. App. at 245. As the preponderance of the evidence is against the claim, the Board finds service connection is not warranted. 4. Service connection for essential hypertension. The Veteran asserts that his hypertension is due to rheumatic fever contracted in service or is due to his service-connected rheumatic heart disorder. He reports that Navy doctors told him he would be susceptible to high blood pressure throughout his life due to his heart disorder or the rheumatic fever. See February 2010 statement from the Veteran. He further contends that rheumatic fever hastened hypertension as it damaged his heart and made it pump harder. See November 2009 statement by Veteran. He also contends that he had hypertension since he was discharged from Marine Corps. Id. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of hypertension, and evidence shows that the Veteran contracted rheumatic fever in service, there is no competent evidence establishing that the Veteran’s hypertension began during service or is otherwise related to an in-service injury, event, or disease. In service, the Veteran contracted rheumatic fever and was subsequently discharged after a medical board review because of his residuals of rheumatic heart disease. Blood pressure on the entrance examination was 130/76. A February 1955 VA examination showed blood pressure was 136/70. A December 1970 VA examination report showed the Veteran reporting being diagnosed with high blood pressure in July 1970. This is over a decade after separation from service, and years after the presumptive period for chronic diseases under 38 U.S.C. §§ 3.307, 3.309. On the other hand, in a November 2009 statement, the Veteran asserted that he has had hypertension since he was discharged from service. In his February 2010 claim form, the Veteran asserted that hypertension began in 1959. The Board finds that the more credible and probative evidence shows that the Veteran did not acquire hypertension until at least 1970. The more credible report is that from the December 1970 VA examination which showed high blood pressure had its onset in July 1970. This report is more credible because it was recorded within 6 months of the onset date. In contrast, the November 2009 statement was made decades after service. No current VA medical examination and medical opinion was rendered in this case. Although a medical opinion was requested, the evidence shows it was cancelled at the request of the Veteran around the time the Veteran was attempting to withdraw the claim. In the May 2020 appellate brief, the Veteran’s representative asked the case to be adjudicated based on the evidence now of record. Accordingly, while a medical opinion was not rendered, the Board interprets the Veteran’s actions and the representative’s statements as a waiver of the right to have a medical opinion rendered. Accordingly, there was substantial compliance with the Board remand directives requesting a medical opinion. Stegall, 11 Vet. App. at 271. The Veteran believes his hypertension is related to an in service rheumatic fever, however, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the etiology and pathophysiology of internal organ systems. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, 492 F.3d at 1377 n.4; see also Kahana, 24. Vet. App. 428. Consequently, a link to service has not been established. As no medical opinion was rendered, there is no competent evidence of a link between the hypertension and rheumatic fever or rheumatic heart disease. A claimant has the responsibility to present and support a claim for benefits under laws administered by the VA, 38 U.S.C. § 5107(a). While VA has a duty to assist the Veteran in substantiating his claim, that duty is not a one-way street. Wood, 1 Vet. App. 190. In February 2010, the Veteran stated that that Navy doctors told him that he would be subject to high blood pressure the rest of his life. The claims file is absent for a probative positive opinion from the medical professionals who the Veteran states told him this. Even assuming that the Veteran is a reliable historian and accurately asserts that such an opinion was provided, because it is not of record, the Board cannot assess the probative value of such a medical opinion. Specifically, the Board is unable to determine the factual basis or rationale supporting the reported opinion. The Veteran’s report that his physician provided a favorable opinion carries little probative weight and is not sufficiently persuasive. The evidence as evaluated above also does not show that hypertension had its onset in service or within the one-year presumptive period following service. It does not credibly assert that hypertension was continuous since separation from service. Accordingly, the chronic disease presumption for hypertension does not apply. 38 C.F.R. §§ 3.307, 3.309. The Board also considers the Veteran’s theory that service connection is warranted on a secondary basis. In other words, the Board considers the Veteran’s contention that his hypertension is secondary to the rheumatic heart disease. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or was aggravated beyond its natural progress by service-connected rheumatic fever. The Board concludes that there is no competent evidence establishing that the Veteran’s hypertension is proximately due to or the result of, or aggravated beyond its natural progression by service-connected rheumatic heart disease. 38 U.S.C. §§ 1110, 1131; Allen, 7 Vet. App. 439; 38 C.F.R. § 3.310(a). A November 1983 private medical opinion states that aortic root dilatation is secondary to hypertension. This is the opposite cause and effect from what the Veteran has claimed. A September 2006 VA medical opinion was rendered. It found that hypertension was not likely secondary to the Veteran’s rheumatic heart disease, finding that there is no physiological relationship between rheumatic heart disease and the development of hypertension. A March 2011 VA medical examination report stated the Veteran’s history and examination finding show evidence of hypertension complications affecting the heart. The Board finds this statement indicates the hypertension is affecting the heart, not the other way around. Again, there was no current medical opinion that might have remedied any inadequacies with these medical opinions. The Board turns to the discussion above for the lack of VA medical opinion. As such, the medical evidence is against a finding that the rheumatic heart disease caused hypertension. Further, there is no medical evidence of that rheumatic heart disease aggravates the Veteran’s hypertension. The Veteran believes his hypertension is proximately due to or the result of/aggravated beyond its natural progression by rheumatic heart disease. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the etiology and pathophysiology of internal organ systems. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau, 492 F.3d at 1377; see also Kahana, 24. Vet. App. 428. (Continued on the next page)   In a September 2006 correspondence, the Veteran pointed to the statement “Your echocardiogram demonstrated changes consistent with history of hypertension and valvular heart disease” in a letter from VA examiner. The Veteran asserted this statement means valvular heart disease caused hypertension. The Board finds that no such cause and effect conclusion is present in the statement. The statement merely shows the co-existence of hypertension and valvular heart disease. As competent evidence of a link between service or service-connected disability and the current disability is not present, the Board finds service connection is not warranted. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Rocktashel, 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.