Citation Nr: 21062722 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 09-08 693 DATE: October 12, 2021 ORDER Entitlement to service connection for a bilateral knee/leg disability, to include as secondary to service-connected bilateral pes planus, is denied. Entitlement to service connection for a bilateral ankle disability, to include as secondary to service-connected bilateral pes planus, is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that the Veteran's currently diagnosed bilateral knee disability began during active service or is otherwise related to an injury or disease in service, to include as caused or aggravated by his service-connected bilateral pes planus. 2. The preponderance of the evidence is against finding that the Veteran's currently diagnosed bilateral ankle disability began during active service or is otherwise related to an injury or disease in service, to include as caused or aggravated by his service-connected bilateral pes planus. CONCLUSIONS OF LAW 1. Service connection for a bilateral knee/leg disability, to include as secondary to service-connected bilateral pes planus, is not warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. Service connection for a bilateral ankle disability, to include as secondary to service-connected bilateral pes planus, is not warranted. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who served on active duty from August 1974 to August 1977. This case is before the Board of Veterans' Appeals (Board) on appeal from a September 2007 Department of Veterans Affairs (VA) rating decision, which in pertinent part denied service connection for bilateral disabilities of the knees, legs, and ankles. In November 2012, the Board remanded the case to the Agency of Original Jurisdiction (AOJ) to afford the Veteran a Travel Board hearing, which was held before the undersigned in March 2013. In July 2014, the Board remanded the case to the AOJ for additional development. A March 2016 Board decision denied service connection for a bilateral knee/leg disability and a bilateral ankle disability. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (CAVC). A March 2017 CAVC Order granted a March 2017 Joint Motion for Remand (JMR) of the parties, thereby vacating the Board's decision and remanding the matters to the Board for action consistent with the terms of the JMR. Thereafter, the Board remanded the case to the AOJ for additional development of the claims in July 2017, August 2019, October 2020, and April 2021. Service Connection 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). Certain chronic diseases, to include arthritis, will be presumed to be service-connected if they were shown as chronic (reliably diagnosed) in service; or, if manifested to a compensable degree within an applicable (one year for arthritis) presumptive period following separation from service; or, if noted in service, with continuity of symptomatology since service. 38 U.S.C. §§ 1101, 1112, 1113; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Some of the Veteran's service treatment records (STRs) are unavailable, despite efforts by the AOJ to obtain them. Active-duty enlistment and separation physical examination reports are not available. The law provides that when, through no fault of the Veteran, records under the control of the government are unavailable, the obligation to explain findings and conclusions and to carefully consider the benefit-of-the-doubt rule is heightened. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991); Pruitt v. Derwinski, 2 Vet. App. 83, 85 (1992); Dixon v. Derwinski, 3 Vet. App. 261, 263 (1992). The Board notes that O'Hare does not raise a presumption that the missing medical records, if available for consideration, would support the claim. That is to say, missing STRs do not lower the threshold for an allowance of a claim; there is no presumption for granting a claim. The legal standard for proving a claim is not lowered; rather, the Board's obligation to discuss and evaluate evidence is heightened. See Russo v. Brown, 9 Vet. App. 46 (1996). The case law does not establish a heightened "benefit of the doubt," only a heightened duty of the Board to consider the applicability of the benefit-of-the-doubt doctrine, to assist the claimant in developing the claim, and to explain its decision when a claimant's medical records have been lost or destroyed. See Ussery v. Brown, 8 Vet. App. 64 (1995). Thus, any missing STRs, alone, do not obviate the need for the Veteran to still have competent and credible evidence supporting his claim for service connection by showing he has the claimed disability and that there is a correlation ("nexus") between his claimed condition and his military service. See Milostan v. Brown, 4 Vet. App. 250, 252 (1993) (citing O'Hare, 1 Vet. App. at 367). 1. Entitlement to service connection for a bilateral knee/leg disability, to include as secondary to service-connected bilateral pes planus The Veteran contends that he has a bilateral knee/leg disability that is attributable to service. He also advances a theory that his bilateral knee/leg disability is secondary to his service-connected pes planus. The initial question before 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 injury, event, or disease in-service. The Board finds that, while the Veteran has current diagnoses of right and left knee disabilities, and evidence shows that he was seen during service with a knee (side unidentified) complaint, the preponderance of the evidence weighs against finding that his current bilateral knee disabilities began during service or are otherwise related to an injury, event, or disease in service. It is further noted that a leg disability separate and distinct from the knee (and ankle) has not been specified by the Veteran or identified on examination. One element necessary to establish service connection is evidence of incurrence of an injury in service. Here, particularly due to the fact that the complete STRs are unavailable, the evidence is slightly limited in determining whether the Veteran sustained injuries to one or both knees during service. It appears, however, that most of the records are available (with service enlistment and separation examination reports missing). They show the Veteran was seen during service in August 1976 with complaints of a trick knee (side not indicated) for two months; the assessment was a lack of muscle tone. Otherwise, there were no right or left knee injuries, complaints, treatment, or diagnoses shown during active-duty service. Although there is no report of a separation physical examination, the claims file contains Illinois Army National Guard records that begin soon after the Veteran's discharge from active duty. These records do not disclose any complaints, treatment, or diagnoses of knee disability. The Veteran was discharged from active duty in August 1977, and the next month on a report of examination for enlistment in the National Guard in September 1977, there were no lower extremity abnormalities. Further, in a report of medical history at that time, he denied arthritis, broken bones, bone, joint or other deformity, or lameness or "trick" or locked knee. In fact, he stated he was "in perfect health." A June 1984 report of examination for the National Guard and a contemporaneous report of medical history were both reflect findings similar to the September 1977 report, with the Veteran stating he was "in good health." Medical records show the Veteran did not have a knee disability diagnosed with decades after his August 1977 separation from active service. A medical history of his bilateral knee treatment includes the following, as shown in VA records: Complaints of a left knee injury at work (hitting knee against a file cabinet) led to X-rays in September 2003, which were normal. An October 2003 MRI was remarkable for significant edema overlying the medial collateral ligament and findings consistent with a sprain; a partial tear involving the femoral attachment could not be ruled out. Other notable findings included early degenerative joint disease (DJD) with mucinous degenerative changes involving the posterior horn of the medial meniscus and injury to the tendon sheath of the vastus medialis tendon and to the medial patellofemoral retinaculum. In January 2004 and February 2004, VA physical medicine and rehabilitation (PM&R) service consult records note that the Veteran injured his left knee in a fall (banging the knee against a cabinet) the previous October and experienced persistent pain ever since then. It also notes that his right knee began to hurt due to favoring of the left knee. A July 2004 orthopedic clinic note indicates the Veteran was seeking worker's compensation benefits. In obtaining additional X-rays in October 2004, it was noted the Veteran fell on his left knee that same day. On a May 2005 general medicine note, the Veteran complained of bilateral knee pain of over two years' duration. The previous night he had fallen on his left knee. Right knee X-rays at that time showed mild degenerative osteoarthritis. Such early records of treatment for the knees do not reflect that the Veteran had any symptoms that were ongoing since his active-duty service. Continued chronic left knee pain resulted in knee surgery at the VA in May 2006, with post-operative diagnoses of left complex medial meniscal tear and grade III chondromalacia trochlear notch, lateral patellar facet, and medial femoral condyle. An August 2007 VA general medicine note shows the Veteran reported a long history of bilateral knee pain, particularly in the left knee after a 2003 fall; the diagnosis was a history of osteoarthritis, multiple monoarticular complaints over the past three years. MRIs of each knee in August 2007 showed various abnormalities. In the left knee, there was a partial tear of the ACL, grade I tendinopathy of the quadriceps and patellar tendons, grade II sprain of the proximal MCL, degeneration of the posterior horn of the medial meniscus, moderate degenerative joint disease of the medial and lateral compartments with grade II chondromalacia, and small Baker's cyst, large joint effusion, and prominent medial patellar plica. In the right knee, there was a complex tear of the posterior horn and body of the medial meniscus with associated multiple small parameniscal cysts, trace knee joint effusion and small Baker's cyst, DJD of the medial and patellofemoral compartments, suspect prior ACL sprain, small marrow replacing process in the proximal tibial metaphysis, and probable old Sinding-Larsen-Johansson disease. Private medical records from University of Illinois Medical Center show treatment for foot and ankle pain complaints. In July 2007, the Veteran was seen for complaints of bilateral knee, ankle, and foot pain, which he stated he had had over six years "on and off." The assessment was oligoarticular inflammatory arthritis. Records in November and December 2008 show continuing complaints of bilateral knee pain. VA outpatient records show that in April 2009 the Veteran reported worsening pain after he injured his left knee when he slipped while descending stairs, and in February 2011 he complained of constant bilateral knee pain after falling on ice. VA examination reports disclose multiple knee diagnoses. In June 2015, the diagnosis was knee joint osteoarthritis, bilaterally. In October 2017, the diagnoses were bilateral knee strain and joint osteoarthritis. In April 2019, the diagnosis was left lateral collateral ligament sprain. In January 2020, the diagnosis was left knee joint osteoarthritis. In November 2020, the diagnoses were contusion, ligament sprain, and degenerative arthritis of the left knee, and degenerative arthritis, ligament sprain, and meniscal tear of the right knee. The June 2021 examiner found the November 2020 report most reliably reflected the current diagnoses. As shown above, medical records in the claims file do not demonstrate that a knee disability was chronic in service, that arthritis of a knee was manifested to a compensable degree within the one-year (chronic disease) presumptive period after service, or that it was noted in service with continuity of symptomatology. Therefore, service connection for a bilateral knee disability under 38 U.S.C. §§ 1110, 1131 and 38 C.F.R. § 3.303(a), based on inception in service, and under 38 U.S.C. § 1112 and 38 C.F.R. §§ 3.307, 3.309, based on presumed incurrence of a chronic disease in service, is not established. While the Veteran is competent to report having experienced symptoms such as knee pain since service, he is not competent to provide a diagnosis in this case or determine that his symptoms were manifestations of a right and/or left knee disability. The issue is medically complex, as it requires knowledge of the pathology of his diagnosed disabilities and the interpretation of complicated diagnostic medical testing such as X-rays and MRIs and of surgical intervention (which confirmed the presence of meniscal tear and chondromalacia in various facets of the left knee). Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran is not shown to possess such specialized medical knowledge, nor has he claimed he has such knowledge. Further, as shown above, contemporaneous National Guard records in September 1977 and June 1984 do not corroborate, but tend to disprove, the Veteran's assertions that he experienced knee symptoms continuously since active service. If he had ongoing symptoms, it is reasonable to expect that he would report them on National Guard reports. Instead, he reported he was in "perfect" or "good" health, and his lower extremities were found to be clinically normal. Such records constitute significant evidence that outweighs any of the Veteran's allegations of ongoing knee symptoms since his discharge from service in August 1977. The Board finds, particularly as the Veteran has not explained his silence regarding knee symptoms on examination and history reports in September 1977 and June 1984 and as his lower extremities were normal on those examinations, that the contemporaneous records are more credible than the Veteran's more current statements about his decades earlier medical history. Nevertheless, under 38 C.F.R. § 3.303(d), service connection may still be granted on a direct basis if the evidence shows that the bilateral knee disability, which was first diagnosed decades after service, is etiologically related to disease or injury in service. A June 2021 VA examiner addresses this question, and the Board deems this opinion to be substantially compliant with the Board's April 2021 remand directives and adequate to decide this claim. In that regard, it is noted that while the examiner did not explicitly reject the Veteran's lay statements of continuing bilateral knee pain after separation from service, he was evidently aware of them and effectively rebutted the statements through his explanations of how the acknowledged complaints in-service had "resolved by separation or at least by the time of the [September 1977 National Guard examination]." Further, he furnished an opinion regarding the likely etiologies of the knee disabilities, apart from an injury or disease in service. Moreover, the June 2021 opinion was furnished by a medical doctor and includes rationale based on consideration of the Veteran's specific contentions and on application of medical principles to the particular facts of this case. The Veteran has not alleged that the opinion is insufficient or that the physician is not competent to provide the requested opinion. The VA examiner opined that the Veteran's bilateral knee disabilities are not at least as likely as not related to an injury, event, or disease in service, to include the notation of knee complaint in service. He reviewed the service and post-service records, finding that the evidence showed the knee condition in service had resolved by the time of the National Guard examination in September 1977. He also found the 1984 National Guard examination was also a "critical document" that showed the Veteran denied knee conditions and his knees were examined. He stated that it was "highly unlikely that such conditions would have gone unnoted or unreported" on this examination. He stated that documentation referencing the knees dated after that examination "represent changes in status arising separate from service as new conditions." He noted various knee injuries documented in the record, stating these injuries "likely contributed greatly" to the Veteran's conditions, but also concluded that the Veteran had "naturally occurring" DJD that was "age-appropriate at the time of diagnosis" and was due to normal wear and tear over time. (In that regard, it is further noted that an earlier VA examiner in April 2011 observed that the Veteran had been employed from 1977 to 1999 in "multiple jobs requiring vigorous physical activities with his lower extremities", which the Board observes would have been inconsistent with a significant chronic knee disability existing since service.) The examiner's 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 record does not contain a conflicting medical opinion regarding whether the Veteran's right and left knee disabilities are at least as likely as not related to an injury, event, or disease in service, to include the knee complaints noted in service. The next question for the Board is whether the Veteran's current bilateral knee disabilities are proximately due to or the result of, or are aggravated beyond natural progress by, a service-connected disability, specifically his bilateral pes planus. The Board finds that, while the Veteran has a current bilateral knee disability (and service-connected pes planus), the preponderance of the evidence is against finding that his bilateral knee disability is secondary to a service-connected disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The June 2021 VA examiner also furnished an opinion that it was less likely than not that the Veteran's bilateral knee disabilities are proximately due to or the result of, or aggravated beyond its natural progression by, his service-connected pes planus. He found it was less likely than not the bilateral pes planus had played any role in the Veteran's knee conditions. In short, he explained that the pes planus did not impact on the Veteran's knee joints. He reviewed the various diagnostic studies in the records to find that the knee diagnoses were instead more likely due to, or aggravated by, "new events" arising after service and "naturally occurring" DJD, which was age-appropriate and arising from normal wear and tear over time. He explained that the knee disabilities were not due to gait accommodation from another joint condition, which was not evident in the Veteran's foot conditions, which were bilateral and equal and thus not susceptible to "dramatic gait alterations." He invoked medical principles in stating that degenerative changes do not "spread from one joint to another." He further stated that there was also no evidence of aggravation of the knees as the DJD was shown to have taken its natural course, which was reflected as a progression over time. The examiner's 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 record does not contain any conflicting medical opinions addressing whether the Veteran's bilateral knee disability is at least as likely as not secondary to his service-connected bilateral pes planus. The Veteran alleges his bilateral knee disability is related to an injury, event, or disease in service. Alternatively, he alleges his bilateral knee disability is proximately due to or the result of (or aggravated beyond its natural progression by) his service-connected bilateral pes planus. However, he is not competent to provide a nexus opinion regarding these issues. The issues are medically complex, as they require knowledge of the pathogenesis of the currently diagnosed disabilities and ability to interpret X-rays, MRIs, and other diagnostic tests. Therefore, the issues are outside the competence of this Veteran case because the record does not show that he has the medical training or credentials to make such determinations. 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 medical evidence, including the June 2021 VA examination report, that has directly addressed the issues. 2. Entitlement to service connection for a bilateral ankle disability, to include as secondary to service-connected bilateral pes planus The Veteran contends that he has a bilateral ankle disability that is attributable to service. He also advances a theory that his bilateral ankle disability is secondary to his service-connected pes planus. The initial 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 injury, event, or disease in service. The Board concludes that, while the Veteran has current diagnoses of right and left ankle disabilities, and evidence shows that he was seen during service with various ankle complaints for a five-month period, the preponderance of the evidence weighs against finding that his bilateral ankle diagnoses began during service or are otherwise related to an injury, event, or disease in service. It is further noted that a leg disability separate and distinct from the ankle has not been specified by the Veteran or identified on examination. One element necessary to establish service connection is evidence of incurrence of an injury in service. Here, particularly as complete STRs are not available, the evidence is somewhat limited in determining whether the Veteran sustained injuries to one or both ankles during service. However, it appears most of the records are available (with active-duty enlistment and separation physical examination reports missing). They show the Veteran was seen during service in June 1976 for a left ankle injury sustained playing basketball, which produced swelling and slight tenderness; X-rays were within normal limits, and the diagnosis was sprain. Later that same month, he was seen for right ankle pain (he said he turned the ankle three weeks previously and it was still sore); X-rays were negative. He was re-evaluated for ankle pain in September 1976, and three days later he was seen on a follow-up for bilateral ankle sprain (the examination was within normal limits). In October 1976, there were complaints of pain in the arch and medial aspect of both ankles for the past five to six months (he was reportedly unable to walk on his ankles after arising in the morning); X-rays of both ankles were negative, and the assessment was no pathology found. Thereafter, no right or left ankle injuries, complaints, treatment, or diagnoses were noted during active-duty service. The Veteran was discharged from active duty in August 1977. Although there is no report of a service separation physical examination in August 1977, the claims file contains the Veteran's Illinois Army National Guard records, which are dated beginning soon after his discharge from active duty. They do not disclose any complaints, treatment, or diagnoses of an ankle disability. On a September 1977 examination for enlistment in the National Guard, no lower extremity abnormalities were found. Further, in a report of medical history at that time, the Veteran denied arthritis, broken bones, bone, and joint or other deformity, and stated he was "in perfect health." A June 1984 report of examination for the National Guard and a contemporaneous report of medical history both reflect findings similar to the September 1977 reports, with the Veteran declaring that he was "in good health." Medical records show the Veteran did not have an ankle disability diagnosed until decades after his August 1977 separation from active service. A medical history of his bilateral ankle treatment includes the following, as shown in VA records: In December 1999, right ankle X-rays showed a possible old avulsion fracture, distal end tibial anteriorly, no demonstrable acute fracture, and calcaneum spur posteriorly. He complained of painful heels on a June 2000 podiatry clinic report (he noted a slip injury in January/February 2000), and X-rays revealed no fracture but degenerative changes at the ankle joint and along the superior aspect of the talus. A January 2001 podiatry note indicates a complaint of continuing painful heels (the Veteran reported a history of injury in January/February 2000, when he was informed of a muscle or tendon injury, and then seen again in June 2000 with continued heel pain). The assessment was bilateral peroneal tendinitis and bilateral plantar fasciitis. A July 2005 nursing note shows a complaint of ankle swelling for seven months. On a June 2006 consult record, the Veteran reported that he felt his ankles gave way sometimes due to weakness; it was noted that a foot X-ray previously showed chronic calcific Achilles' tendinitis. A September 2006 podiatry note indicates a vegetable cart ran over the Veteran's right foot; X-rays of the right foot showed chronic calcific Achilles' tendinitis and osteoarthritis of the mid-foot, hammertoe deformity, and small bone spur on plantar aspect of the calcaneus. A February 2007 PM&R service consult report indicates that he was seen for ankle (and foot and knee) pain, mostly upon standing and walking. He felt that his ankles sometimes gave way due to weakness. It was noted he worked at a restaurant eight hours a day and was on his feet. A May 2013 emergency department record shows the Veteran was seen with complaints of ankle pain that he said had persisted since service. A May 2013 general medicine note indicates that X-rays showed ankle degenerative joint disease. Private medical records from University of Illinois Medical Center show treatment for foot and ankle pain complaints. In July 2007, the Veteran was seen for complaints of bilateral knee, ankle, and foot pain, which he stated he has had over six years "on and off." The assessment was oligoarticular inflammatory arthritis. VA examination reports disclose various ankle diagnoses. In June 2015, the diagnosis was lateral collateral ligament sprain, bilaterally. In October 2017, the diagnosis was deltoid ligament sprain, bilaterally. In April 2019, the diagnosis was lateral collateral ligament sprain on the left. (In January 2020, the examiner stated there was no current diagnosis.) In November 2020, the diagnoses were bilateral ankle sprain (resolved with treatment) and bilateral ankle tendinitis. The June 2021 examiner found the November 2020 report most reliably reflected the current diagnoses, with the exception that it did not note the old, healed fracture of the ankle occurring after service. As shown above, medical records in the claims file do not demonstrate that an ankle disability was chronic in service (there were notations only for the period from June 1976 to October 1976), that arthritis of an ankle was manifested to a compensable degree within the one-year (chronic disease) presumptive period after service, or that it was noted in service with continuity of symptomatology. Therefore, service connection for a bilateral ankle disability under 38 U.S.C. §§ 1110, 1131 and 38 C.F.R. § 3.303(a), based on inception in service, and under 38 U.S.C. § 1112 and 38 C.F.R. §§ 3.307, 3.309, based on presumed incurrence of a chronic disease in service, is not established. While the Veteran is competent to report having experienced symptoms such as pain of the ankles since service, he is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of a right and/or left ankle disability. The issue is medically complex, as it requires knowledge of the pathology of his diagnosed disabilities and the interpretation of complicated diagnostic medical testing such as X-rays. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran has not been shown to possess such specialized medical knowledge, nor has he claimed to possess such knowledge. Further, as shown above, contemporaneous National Guard records in September 1977 and June 1984 do not corroborate, but tend to disprove, the Veteran's assertions that he experienced ankle symptoms continuously since active service. If he had ongoing symptoms, it is reasonable to expect that he would have reported them on National Guard examination reports. Instead, he wrote that he was in "perfect" or "good" health, and his lower extremities were found to be clinically normal at that time. Such records constitute significant evidence that outweighs any of the Veteran's allegations of ongoing ankle symptoms since his discharge from service in August 1977. Moreover, the Board finds, particularly as the Veteran has not explained his silence regarding ankle symptoms on examination and history reports in September 1977 and June 1984 and as his lower extremities were normal on those examinations, that such contemporaneous records are more credible than his more current statements about his decades earlier medical history. Nevertheless, under 38 C.F.R. § 3.303(d), service connection may still be granted on a direct basis if the evidence shows that the bilateral ankle disability, which was first diagnosed decades after service, is etiologically related to in-service disease or injury. A June 2021 VA examiner addresses this question, and the Board deems this opinion to be substantially compliant with the Board's April 2021 remand directives and adequate to decide this claim. In that regard, it is noted that while the examiner did not explicitly reject the Veteran's lay statements of continuing bilateral ankle pain after separation from service, he was evidently aware of them and effectively rebutted the statements by his explanations of how the acknowledged complaints in-service had "resolved by separation or at least by the time of the [September 1977 National Guard examination]." Further, he furnished an opinion regarding the likely etiologies of the ankle disabilities, apart from an injury or disease in service. Moreover, the June 2021 opinion was furnished by a medical doctor and includes rationale based on consideration of the Veteran's specific contentions and application of medical principles to the particular facts of this case. The Veteran has not alleged that the opinion is insufficient or that the physician is not competent to provide the requested opinion. The VA examiner opined that the Veteran's bilateral ankle disabilities are not at least as likely as not related to an in-service injury, event, or disease, including the ankle complaints noted in service. Similar to the knee discussion above, he reviewed the service and post-service records, finding that the evidence showed the bilateral ankle conditions in service had resolved by the time of the September 1977 National Guard examination. He also deemed the 1984 National Guard examination report to be a "critical document," showing not only that the Veteran denied ankle conditions at that time but also that no ankle conditions were found on examination. He stated that it is "highly unlikely that such conditions would have gone unnoted or unreported" on this examination. He stated that documentation referencing the ankles dated after that examination "represent changes in status arising separate from service as new conditions." He found that ankle injuries after 1984 "likely contributed greatly" to the Veteran's current conditions and that the Veteran also had "naturally occurring" DJD that was "age-appropriate at the time of diagnosis" and was due to normal wear and tear over time. (In that regard, it is further noted that an earlier VA examiner in April 2011 observed that the Veteran had been employed from 1977 to 1999 in "multiple jobs requiring vigorous physical activities with his lower extremities.") He addressed the December 1999 right ankle X-ray finding of a possible old resolved fracture of the distal tibia, stating that this clearly occurred after service as X-rays in service were negative. The examiner's 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 record does not contain a conflicting medical opinion regarding whether the Veteran's right and left ankle disabilities are at least as likely as not related to an injury, event, or disease in service, to include the bilateral ankle complaints noted in service. The analysis turns to is whether the Veteran's current bilateral ankle disabilities are proximately due to or the result of, or are aggravated beyond natural progress by, a service-connected disability, specifically bilateral pes planus. The Board concludes that, while the Veteran has a current bilateral ankle disability, and service-connected bilateral pes planus the preponderance of the evidence is against finding that his bilateral ankle disability is secondary to the pes planus disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). The June 2021 VA examiner also furnished on opinion that it was less likely than not that the Veteran's bilateral ankle disabilities are proximately due to or the result of, or aggravated beyond its natural progression by, the service-connected bilateral pes planus. He found it was less likely than not the bilateral pes planus had played any role in the Veteran's ankle conditions, that is, he essentially concluded that the pes planus did not impact on the Veteran's ankle joints. He reviewed the various diagnostic studies in the records to find that the ankle diagnoses were instead more likely due to, or aggravated by, "new events" arising after service and "naturally occurring" DJD, which was age-appropriate and arising from normal wear and tear over time. He explained how the Veteran's ankle disabilities are not due to any gait accommodation from another joint condition (which was rare), particularly as his foot conditions were bilateral and equal and thus would not be susceptible to "dramatic gait alterations." He invoked medical principles in stating that degenerative changes do not "spread from one joint to another." He further stated that there is no evidence of aggravation of the ankles because the DJD was shown to have taken its natural course, which was reflected as a progression over time. The examiner's opinion is probative evidence, as 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 record does not contain a conflicting medical opinion addressing whether the Veteran's bilateral ankle disability is secondary to his service-connected pes planus. The Veteran alleges his bilateral ankle disability is related to an injury, event, or disease in service. Alternatively, he alleges his bilateral ankle disability is proximately due to or the result of (or aggravated beyond its natural progression by) his service-connected bilateral pes planus. However, he is not competent to provide a nexus opinion regarding these issues. The issues are medically complex, as it requires knowledge of the pathogenesis of his currently diagnosed disabilities and the ability to interpret X-rays and other diagnostic tests. Therefore, the issues are outside the competence of this Veteran because the record does not show that he has the medical training or credentials to make such determinations. 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 medical evidence, including the June 2021 VA examination report, that directly addressed the issues. George R. Senyk Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Debbie Breitbeil, 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.