Citation Nr: 21068066 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 16-47 000 DATE: November 9, 2021 ORDER Entitlement to service connection for gout of the right great toe is denied. INTRODUCTION The Veteran served on active duty in the U.S. Air Force from June 1962 to June 1982. When this matter was previously before the Board in November 2018, October 2020, and September 2021 the above-noted issue was remanded for additional development. The case has since been returned for further appellate review. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran's gout began during active service, or is otherwise related to an in-service injury, event, or disease, and the most probative evidence indicates the condition is not etiologically related to his service-connected right ankle disability. CONCLUSION OF LAW The criteria for service connection for right great toe gout have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION Duty to Assist The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C. §§ 5103, 5103A, and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159, provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. The Board finds VA has complied with its duty to assist the Veteran in the development of his claim. In this respect, all available service treatment records (STRs) and post-service medical evidence identified by the Veteran have been obtained. The Veteran was afforded an opportunity for a hearing before a Decision Review Officer or before the Board, but declined to do so. Further, the Veteran was afforded appropriate VA examinations and medical opinions were obtained addressing his claimed gout on several occasions. Neither the Veteran nor his representative have identified any outstanding, existing evidence that could be obtained to substantiate the claim; the Board is also unaware of any such evidence. Therefore, the Board is satisfied that VA has complied with its duty to assist the Veteran in the development of the claim. Accordingly, the Board will address the merits of the Veteran's claim. Burden of Proof Except as otherwise provided by law, a claimant has the responsibility to present and support a claim for benefits under laws administered by the Secretary. The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Legal Criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. 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 disability which is proximately due to or the result of service-connected disability. 38 C.F.R. § 3.310 (a). Factual Background and Analysis The Veteran asserts service connection is warranted for gout, because the disability was either incurred in service or is consequentially related to his service-connected right ankle disability. At the outset, the Board notes the Veteran has been diagnosed with right great toe gout during the appeal period. As such, the central issues that must be determined are whether his condition was incurred in service, or alternatively, whether the disability was caused or aggravated by his service-connected right ankle disability. In sum, the Board finds the overwhelming evidence is against the claim. Initially, a review of the Veteran's STRs fails to show he was ever treated for or diagnosed with gout in service, and the Veteran has not alleged the disability onset therein. Rather, the Veteran has asserted that as a result of extensive standing and walking in service he developed gout. In this respect, the Board notes a layperson is competent to testify in regard to the onset and continuity of symptomatology. Heuer v. Brown, 7 Vet. App. 379, 384 (1995); Falzone v. Brown, 8 Vet. App. 398, 403 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). However, it is the province of trained health care professionals to enter conclusions that require medical expertise, such as opinions as to diagnosis and causation. Jones v. Brown, 7 Vet. App. 134, 137 (1994). For example, a veteran is competent to state that he experiences symptoms that are commonly associated with gout, such as toe pain, but he is not competent to explain the complex etiology of gout. In this respect, the RO obtained several medical opinions which have addressed the Veteran's assertion that extensive walking and standing in service caused his current disability. In particular, the Board notes a statement from the examiner who performed the Veteran's September 2017 VA non-degenerative arthritis examination. Following that examination, the examiner explained that gout is a metabolic disorder of uric acid production or excretion. Further, a May 2019 VA examiner concluded the Veteran's claimed disability was less likely than not incurred in service, as it did not develop until 2013, which was more than 30 years after the Veteran's discharge from active duty. In a January 2021 medical opinion, a third VA examiner found the Veteran's disability was less likely than not incurred in service. This examiner again explained the condition is caused by the presence of monosodium urate crystals in the joints, bones, and soft tissues. The examiner further explained that hyperuricemiaor elevated urate concentrationis the necessary pathogenic factor in the development of gout, and is not caused or increased by standing or walking. Based on the foregoing, the Board finds the great preponderance of the evidence is against a finding that the Veteran's gout was incurred in service. This follows, because the Veteran's STRs fail to show treatment for or a diagnosis of the disability, and several competent medical clinicians have found no evidence to support the incurrence of the disability in service. The Board has also considered the Veteran's alternative secondary theory of causation in this case. Specifically, the Veteran has asserted "it is possible" his service-connected right ankle disability "contributed to" his gout. Initially, the Board notes the Veteran has not explained in any way how or why he believes the two conditions are consequentially related. Moreover, the RO has obtained several VA medical opinions addressing the Veteran's blank assertion. In particular, the September 2017 VA examiner found no evidence in the medical literature to support the existence of a causal association between ankle degenerative joint disease and right great toe gout. She explained there is simply no physiological mechanism by which wear and tear of a joint causes or contributes to the development of uric acid deposition in another joint. Additionally, after comprehensively reviewing the Veteran's file, the examiner who provided the January 2021 medical opinions found no medical evidence indicating the Veteran's gout was aggravated by his right ankle disability. The Veteran underwent a third VA foot examination in June 2021. Following that examination, the physician again found no causation or aggravation of the Veteran's gout by his service-connected right ankle disability. This examiner again found no medical literature support for the contention that degenerative arthritis of the ankle could cause or aggravate gout. The Board has carefully reviewed all of the Veteran's private clinical records and outpatient treatment notes from the Oklahoma City, Fort Worth, and Wichita Falls VAMCs. However, these records also provide no evidence linking the Veteran's current gout disability to either his military service or his service-connected right ankle disability. In sum, the Board finds the totality of the evidence weighs heavily against the Veteran's claims. Numerous competent medical clinicians have found no link between the claimed condition and Veteran's military service. Likewise, several clinicians have found no link between the condition and the Veteran's service-connected right ankle disability. Moreover, the Veteran has not explained in any way how or why his ankle disability could have caused or impacted upon his right toe gout. Therefore, the claim must be denied. In reaching this decision, the Board has considered the doctrine of reasonable doubt but has determined that it is not applicable to this claim because the preponderance of the evidence is profoundly against the claim. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Fraser, 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.