Citation Nr: 21074737 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 10-13 994A DATE: December 16, 2021 ORDER Service connection for bilateral pes planus is granted. Service connection for a lumbar spine disability to include as secondary to multiple service-connected orthopedic disabilities, is denied. Service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected posttraumatic stress disorder (PTSD), is denied. FINDINGS OF FACT 1. The competent and credible evidence is at least at equipoise as to whether the Veteran's bilateral pes planus is related to service. 2. The most probative evidence of record shows that the Veteran's diagnosed lumbar spine disabilities are not due to his active military service and are not proximately caused by or aggravated beyond their natural progression by his service-connected orthopedic disabilities. 3. The most probative evidence of record shows that the Veteran's diagnosed OSA is not due to his active military service and is not proximately caused by or aggravated beyond its natural progression by his service-connected PTSD. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for bilateral pes planus are met. 38 U.S.C. §§ 1110, 1154, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for a lumbar spine disability are not met. 38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for OSA are not met. 38 U.S.C. §§ 1110, 1111, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Navy from August 1984 to August 2004. These claims come before the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Veteran timely filed a notice of disagreement (NOD) in November 2009 and substantive appeal in April 2010. In July 2016, the Veteran testified before a Veterans Law Judge (VLJ). A transcript of the hearing is of record. In September 2016, the Board granted service connection for hemorrhoids and remanded the remaining claims for further development. In February 2018, the Board denied increased rating claims for service-connected knee and left shoulder disabilities and remanded the claims for service connection for OSA, a low back disability, and a bilateral foot disability for additional evidentiary development. In February 2021, the Board denied entitlement to a total disability rating based upon individual unemployability due to service-connected disabilities (TDIU) and remanded the remaining claims for further development. In April 2021 and September 2021, the Veteran was informed that the VLJ he testified in front of in July 2016 had retired. He did not indicate that he wished to appear at another Board hearing. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for a claimed disability may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service-connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected; if a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). In addition, such chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101(3), 1112(a)(1), 1113; 38 C.F.R. §§ 3.307(a), 3.309(a). A veteran is presumed to have been sound upon entry into active service, except as to defects, infirmities, or disorders noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b). In other words, "[w]hen no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry." Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). 1. Service connection for bilateral pes planus The Veteran contends that his bilateral foot disabilities are due to his active military service. Specifically, he contends that that he worked in engineering and wore tight boots which caused his foot problems. Notably, the Veteran is in receipt of service connection for athlete's feet with tinea onychomycosis, one of the foot disabilities he has mentioned throughout the entirety of the appeal. Service treatment records (STRs) reflect that the August 1984 entrance report of medical examination reflects a normal clinical evaluation for the feet. In October 1984, the Veteran was seen for sore arches, athlete's foot, and edema. There was pain on examination. He was assessed with pes planus. A January 1989 report of medical history reflects that the Veteran reported foot trouble. The examiner noted athlete's foot. A June 1999 report of medical history report reflects that a history of plantar fasciitis. In November 2004, the Veteran had a corn between the fourth toe. He reported that he trimmed his soft corns to alleviate pain. There were no other pedal issues. There was a low arch on/off weight bearing bilaterally. There was full range of motion on all pedal joints without pain or crepitus. He was assessed with onychomycosis, pes planus (asymptomatic), adductovarus, and soft corn/heloma molle. The Veteran's May 2004 separation report of medical history reflects that the Veteran indicated that he had foot trouble. He noted that he had athlete's foot. The contemporaneous separation report of medical assessment reflects that the Veteran conveyed that he sought medical care for his feet. Finally, the separation (referred also as the retirement examination) reflects a normal clinical evaluation for the feet, Post-service, an October 2005 VA treatment note shows that a clinician evaluated the Veteran for orthotics and his main complaint was bilateral pes planus. In a December 2009 VA treatment note, a clinician reported that the Veteran had a history of pain and callus between the fourth and fifth digit in his right foot. In a January 2010 VA treatment note, a clinician noted a corn between the Veteran's toes. In October 2010, the Veteran underwent right fifth toe exostectomy hammertoe procedure ay a VA facility. In a September 2015 Disability Benefits Questionnaire (DBQ), a clinician diagnosed flat feet (pes planus). The clinician also provided a diagnosis of status post hammer toe repair, right fifth toe. The Veteran reported that the date of onset of the symptoms was July 1998. He reported that he wore military-issued boots for extended periods of time during active-duty service. The condition had worsened significantly. The Veteran underwent surgery in 2005 for hammer toe; fungus build up; pain when walking; arch numbness; and tenderness on both outside small toes. The clinician opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As a rationale for this negative nexus opinion, the clinician reported opined that STRs do not reveal evidence of pes planus. In an October 2015 VA addendum opinion, a clinician opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale for this negative nexus opinion, this clinician reported that he reviewed all of the pertinent records which reflect that STRs show that he was seen in October 1984 for an athlete's foot rash with foot pain and associated cracks in the skin. An examiner did not report pain with palpation of the arch structure and flat feet were incidental. The condition (presumably pes planus) was clearly present when he entered service and was not aggravated beyond the natural progression of the condition. He concluded that there were no persistent or recurrent sequelae of the claimed issue noted in service. During a July 2016 Board hearing, the Veteran testified that he worked in engineering and wore tight boots which caused his foot problems. In a March 2017 DBQ, a clinician diagnosed bilateral flat foot (pes planus) and plantar fasciitis on the right foot. The Veteran endorsed numbness; shock to toes; soreness to the heels of feet; and pain to the sides of his right foot. He reported that he has always had foot problems throughout service because of boots. The clinician opined that based upon a review of the record and examination of the Veteran, for each diagnosed disability of the feet, to include bilateral pes planus, it is not at least as likely as not (a 50 percent or better probability) that the disability is attributable to service. As rationale for this negative nexus opinion, the clinician reported that the claims file lacks objective medical evidence to confirm diagnosis or treatment for bilateral plantar fasciitis and right 5th digit exostosis/exostectomy during military service. The clinician reported that bilateral pes planus was a preexisting condition. He reported that while evidence of record indicates pes planus was present at enlistment, there is no documentation indicating chronic or continued care while in service. There is no evidence of record to confirm diagnosis or treatment of right foot 5th digit exostosis while in service. In a June 2017 VA treatment note, a clinician reported that bilateral mild pes planus deformity was present upon imaging. VA treatment records from September 2017 reflect that the Veteran was assessed with foot pain pressure and joint right plantar foot peroneal strain on the right lateral foot. Upon examination, the clinician reported that foot pronation was due to genu varum knees bilateral. Moreover, the clinician noted that the Veteran's right limb is shorter that his left limb. The Veteran endorsed pain at the bottom of the feet and toes. In an August 2019 radiology report, a clinician noted that the Veteran had post-surgical changes at the fifth IP joint. There were mild degenerative changes at the first metatarsophalangeal joint. Also, hindfoot valgus and pes planus were present. In a September 2020 VA opinion, a clinician opined that the claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. As rationale for this negative nexus opinion, the clinician reported that STRs were silent for right foot problems. A retirement examination in 2004 was silent for foot problems. The Veteran underwent surgery on the right foot 5th toe due to exostosis in 2010 after retirement from service in 2004. Periodic examinations in service, including the retirement examination, show no evidence of bilateral pes planus or other foot deformities. Therefore, it remained unclear whether the condition pre-existed service. In an April 2021 VA opinion, a clinician reported that he was able to determine a baseline level of severity of the bilateral foot condition based upon medical evidence available prior to aggravation described as right foot plantar pain. The clinician reported that this is not the current level of severity as it was status post right fifth toe surgery. The clinician reported that bilateral feet conditions with pain, other than the fungal infections, were not aggravated beyond their natural progressions by service-connected bilateral knee disabilities. This clinician opined that the bilateral foot condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected bilateral knee disability. The clinician reported that the records reflect a normal gait and no complaint of feet issues until July 2017, which suggest current bilateral feet were not the result of over-compensation for the knee joints from service. Finally, the clinician opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. He noted the Veteran's reported sore arches or foot pain experienced during service as the result of boots in services. This clinician reported that STRs do not contain clinical notes of feet issues throughout active service. He stated that the Veteran had an occupation as a supervisor in court which required standing and walking, occupation in administration, and he reported normal gait and no complaint of feet issues until the August 2020 VA examination. This suggests that the current bilateral feet were not the result of wearing boots during active-duty service. Upon review of the evidence of record, service connection for bilateral pes planus, solely, is warranted. The Veteran has a current diagnosis of bilateral pes planus, plantar fasciitis on the right foot, and exostosis status post exostectomy, right fifth toe. Thus, the dispositive issue in this case is whether the Veteran's bilateral foot disabilities are related to service. As an initial matter as indicated above, unless a disorder is noted at entry into service, a veteran is presumed sound in this regard unless there is clear and unmistakable evidence that shows the disorder preexisted service and was not aggravated thereby. 38 U.S.C. § 1111. The August 1984 entrance report of medical examination reflects a normal clinical evaluation for the feetbilateral pes planus was not noted at entry. Thus, the Board must determine whether there is clear and unmistakable evidence that shows that this disorder preexisted service. In the October 2015 addendum opinion, the clinician reported that the condition was clearly present when he entered service. The March 2017 clinician reported that bilateral pes planus was a preexisting condition and that the evidence of record indicates pes planus was present upon enlistment. The September 2020 clinician reported that the bilateral foot disability clearly and unmistakably existed prior to service; however, explained in his rationale that it is not clear that the condition pre-existed service. These opinions, as a totality, do not reflect an accurate representation of the evidence of record. As articulated above, the Veteran's entrance report of medical examination showed a normal clinical evaluation of the feet. As such, a finding that bilateral pes planus clearly and unmistakably existed prior to service must be explained. None of the clinicians offered a sufficient rationale to support their findings that the Veteran's bilateral pes planus pre-existed service. There were no explanations about how bilateral pes planus can develop, to include whether the condition is hereditary trait or whether it can develop over time. While the Veteran's pes planus was assessed two months following entrance, there was no explanation as to why it was assessed at that time and not upon entrance and whether it could have developed over time. Thus, as there is a lack of adequate rationales from the clinicians as a whole, there is no clear and unmistakable evidence that discloses that the Veteran's bilateral pes planus preexisted service. Again, the Veteran is presumed sound upon entry into service The evidence of record reflects that in service, the Veteran was diagnosed with bilateral pes planus. Additionally, upon separation from active-duty service, the Veteran reported foot problems. Notably, a clinician indicated the presence of bilateral pes planus in October 2005just over a year from separation. The medical evidence of record continues to show a consistent diagnosis of bilateral pes planus. Finally, the Veteran has regularly reported foot painat times associated with his bilateral pes planus. The Veteran is competent to report ongoing discernable symptomatology, and there is no reason to doubt his credibility in this regard. See Jandreau v. Nicholson, 492 F. 3d 1372, 1377, 1377 (Fed. Cir. 2007); see also Walker, 708 F. 3d 133. The DBQ reports collectively reflect a lack of a relationship between the Veteran's current bilateral pes planus and his military service. However, the clinicians did not take into consideration the entirety of the Veteran's STRs; specifically, the in-service notation of bilateral pes planus that was not noted on entrance. Additionally, bilateral pes planus was consistently noted following its initial diagnosis. Thus, these opinions are of highly diminished probative value. See Buchanan v. Nicholson, 451 F. 3d 1331, 1336 (Fed. Cir. 2006) (noting that a VA's examiner's opinion, which relied on the absence of contemporaneous medical evidence, "failed to consider whether the lay statements presented sufficient evidence of the etiology of [the veteran's] disability such that his claim for service connection could be proven without contemporaneous medical evidence"). Finally, the Veteran does have an additional diagnosis of exostosis status post exostectomy, right fifth toe and plantar fasciitis on the right foot. However, service connection is not warranted for this disability. The March 2017 examiner found that there is no evidence of record to confirm diagnosis or treatment of right foot 5th digit exostosis while the Veteran was in active-duty service. As the clinician explained the reasons for his conclusions based upon an accurate characterization of the evidence of record, the opinion is entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). This opinion aligns with the medical evidence of record. STRs fail to show a diagnosis, treatment, or symptoms of exostosis and plantar fasciitis. These maladies were diagnosed years after the Veteran's separation. There is competent and probative medical evidence with substantial and adequate To the extent that the Veteran has opined that his exostosis/hammertoe and plantar fasciitis is related to service, lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case-by-case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F. 3d 1313, 1316 (Fed. Cir. 2009). In this case, the Veteran's contentions as to the etiology of his foot disabilities relate to an internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Jandreau, 492 F. 3d 1372. The Veteran's statements are therefore not competent medical evidence. To the extent that these lay statements are credible, the Board finds the specific, reasoned opinion of the VA examiner to be of far greater probative weight. Considering the above, specifically the Veteran's statements of ongoing symptomatology and the contemporaneous medical records, the Board finds the evidence is at least in equipoise as to whether the Veteran's current bilateral pes planus began during service. However, the preponderance of the evidence is against the claim for exostosis/hammer toe and plantar fasciitis in the right foot. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Service connection for a lumbar spine disability to include as secondary to multiple service-connected orthopedic disabilities The Veteran contends that his diagnosed lumbar spine disabilities are due to his active military service, or in the alternative, secondary to his service-connected orthopedic disabilities. Service treatment records reflect that in June 1993, the Veteran complained of back pain after he collided with another person playing baseball. Upon examination, he had full range of motion, he was not tender to palpation, and the straight leg testing was negative. In October 1993, the Veteran complained of low back pain. Upon examination, his back was nontender to palpation. The Veteran pointed to his left hip area as the area of pain. He had full range of motion, but he was not well balanced due to left knee surgery. In December 1994, the Veteran reported upper back self-reported nerve pain. In September 1997, the Veteran complained of lower back/side pain that he had for one day. He reported that he thought that this was attributable to his kidney. He reported that he noticed the pain while walking and sometimes while sitting. He had a small nodule noted on the upper left iliac crest. He was told to take Motrin. In the June 1999 report of medical history, the Veteran reported recurrent back pain. The clinician noted a history of musculoskeletal lower back pain. On the May 2004 separation report of medical history, the Veteran reported that he had multiple medical issues of chronic arthritis. He specifically listed his knees, ankle, feet, shoulder, and neck. The corresponding separation report of medical history reflects a normal clinical evaluation for the spine. Post-service, a January 2013 radiology report of the lumbar spine reflects L4-L4 left eccentric peripheral annular fissure, left small foraminal disc protrusion causing moderate left neural foraminal narrowing. There was no severe central canal compromise within the lumbar spine. In a September 2015 DBQ report, a clinician diagnosed lumbosacral strain. The Veteran reported that the date of onset of his spine symptoms was September 1997. He reported that he was unable to move freely and had problems walking with pain radiating to his hips and lower back, and inflammation. The clinician opined that the condition claimed was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As a rationale for this negative nexus opinion, the clinician reported that all pertinent records only show that the Veteran had two isolated spine pain incidents in service. The Veteran, on these occasions, was treated conservatively for muscle strain and recovered without any residual effects. The clinician concluded that the Veteran's current back condition is degenerative, the result of chronic wear and tear, genetic predisposition, and the loss of fluid in disk spaces. An April 2016 radiology report disclosed L2-L3, L3-L4, and L4-L5 left eccentric disc bulge or foraminal protrusion with moderate left neural foraminal stenosis, most pronounced at L4-L5. There was no significant lumbar spinal canal stenosis. During the July 2016 Board hearing, the Veteran testified that he was going to physical therapy for his back. He testified that he went to pain management for his whole body since 1993. He was involved in boxing, football, sports, baseball in 1993. He conveyed that he first injured it when he was playing sports and was working on lifting weights at the same time. He testified that his lumbar spine disability is secondary to his knees. In a March 2017 DBQ report, a VA clinician provided diagnoses of degenerative arthritis of the spine and sciatica. The Veteran reported that he first started noticing back pain in 1993. The clinician opined that it is not at least as likely as not that the claimed low back disability either began in service or is related to service. As a rationale for this negative nexus opinion, the clinician reported that while the evidence of record indicated treatment for two acute episodes of low back pain during service, there is simply no documentation of record to show injury, continued care, and treatment of initial condition during service. Indeed, the clinician emphasized that there is a 9-year gap between service and diagnosis. Moreover, the clinician reported that he was unable to confirm that the Veteran's current low back condition was related to an injury that occurred during service without resorting to mere speculation. The clinician indicated that a nexus could not be established. The clinician also opined that it is not at least as likely as not the Veteran's service-connected bilateral knee disabilities proximately caused by or aggravated the Veteran's low back disability beyond its natural progression. As a rationale for this negative nexus opinion as to secondary service connection, the clinician reported that the two disabilities are not medically related. The claimed disorder of low back disability is a separate entity from the service-connected conditions of bilateral knee disabilities and unrelated to it in any way. Furthermore, there was no evidence of record to support the contention that the bilateral knee disabilities aggravated the Veteran's lower back in any way. Radiology imaging from 2019 reflect minimal osteoarthritic change present in the lower dorsal spine. In a September 2020 DBQ report, a clinician provided a diagnosis of disc bulges of the lumbar spine. The Veteran reported that the condition started in 1990s due to physical activities and playing sports. The Veteran reported symptoms of pain from 2000. Also, he reported it was treated with a back brace and pain management. The clinician opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale for this negative nexus opinion, the clinician reported that STRs indicate an incident of low back pain in 1997. Following that, there are no further chronic or recurring complaints to establish chronicity and the Veteran's retirement examination in 2004 is silent for back complaints. This clinician also found that the claimed condition is less likely than not proximately due to or the result of the Veteran's service-connected conditions. As rationale here, the clinician reported that knee disabilities are not a medically established cause of disc bulges. In an October 2020 VA medical opinion, a clinician reported that he could not determine a baseline level of severity of the lumbar spine based on medical evidence available prior to aggravation or the earliest medical evidence following aggravation by service-connected knee disability. The Veteran's lumbar spine disability is not at least as likely as not aggravated beyond its natural progression. As rationale here, the clinician reported that the Veteran's medical records indicate a history of back pain in 2009 associated with exercising and he has lower back pain with radicular symptoms. His MRI in 2016 confirmed disc bulges in the lumbar spine. Disc bulges and arthritis in the lumbar spine cause chronic low back pain with radicular symptoms. The lumbar disc bulges and arthritis is caused by direct trauma to the lower back and part of normal aging process. Therefore, the Veteran's service-connected bilateral knee disabilities less likely than not aggravated the Veteran's low back disability in any way. In an April 2021 VA medical opinion, a clinician opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale for this negative nexus opinion, the clinician reported that the low back disability is less likely than not incurred in or caused by the reported back pain during service. STRs reflect a singular note in September 1997 of lower back pain for one day with no recurrence throughout the rest of active service and the earliest mention of post service lower back pain occurred in June 2009 with a normal radiology. An October 2009 treatment note reports possible cause of back pain for past few weeks was due to suspected drug reaction of Zocor and radiology of the lumbar spine in April 2016 reporting disc bulging suggested current lower back condition was not the result of active service. The clinician opined that the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. The clinician reported that he could determine a baseline level of severity of the lumbar spine disability based upon medical evidence available prior to aggravation or the earliest medical evidence following aggravation by the service-connected neck strain. In a 2009 record, a VA clinician reported some back pain. The current severity of the lumbar spine was not greater than the baseline. The clinician opined that the low back condition was not aggravated by the service-connected neck disability, bilateral shoulder disability, bilateral ankle disability, and/or bilateral knee disability. The clinician opined that January 2009 clinical note showed that the Veteran's worked as a court supervisoran occupation which required significant standing and walking. Moreover, an August 2009 report showed that the Veteran works in administration, again an occupation which required significant standing and walking. Treatment notes from March 2010, June 2012, October 2013, and June 2016 include findings of normal gait. Upon examination in August 2020, the Veteran complained of issues with his feet, albeit with normal gait. The earliest mention of lower back pain occurred in September 1997 for one day (SI Joint discomfort) with no recurrence throughout the rest of active service and the earliest mention of post service lower back pain was noted in June 2009 with normal radiology of the lumbar spine. An October 2009 treatment note reports possible cause of back pain for past few weeks was due to suspected drug reaction of Zocor. An April 2016 radiology of the lumbar spine reporting disc bulging which suggests that the Veteran's current lower back condition was not aggravated in any way by service-connected disabilities. In May 2021 correspondence, the Veteran, through his representative, submitted a medical treatise which, in pertinent part, represented that all the musculoskeletal systems are interrelated. While the Board recognizes the generic value of this treatise, it contains no findings which are specific to the facts of the Veteran's medical history or clinical status. As such, the Board assigns diminished probative weight to this generic material. Guerrieri v. Brown, 7 Vet. App. 467 (1993). Upon review of the evidence of record, service connection for a lumbar spine disability, to include as secondary to service-connected orthopedic disabilities, is not warranted. Initially, the Veteran has a current diagnosis of degenerative arthritis and disc bulges, lumbar spine. Thus, the question remains as to whether his lumbar spine disabilities are due to his active military service, to include in-service complaints of back pain. The collective VA medical opinions of record, as a totality, found that the Veteran's lumbar spine disability was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The clinicians noted that each time that the Veteran was seen in service, he fully recovered from the complaint of back pain without residual effects. The September 2015 clinician attributed his back disability to degenerative changesthe result of chronic wear and tear, a genetic predisposition, and the loss of fluid in disk spaces. Additionally, the 2021 VA clinician noted that the Veteran's careers have required him to stand and walk for long periods of time and his earliest complaint of back pain dates from 2009. As the clinicians explained the reasons for their conclusions based on an accurate characterization of the evidence of record, the opinions are entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. 295. To the extent that the Veteran, including through his representative, has opined that his lumbar spine disabilities are related to service or to his service-connected disabilities, lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case-by case basis whether a veteran's particular disability is the type of disability for-which lay evidence is competent. See Davidson, 581 F. 3d 1313. Here, the Veteran's contentions as to the etiology of his lumbar spine disabilities relate to an internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Jandreau, 492 F. 3d 1372. While the STRs show complaint of back pain, the last complaint the Veteran had was in 1999five years before the Veteran separated from service. Notably, upon separation, he listed out all his orthopedic complaints and did not indicate that he had any back disabilities or pain. The Veteran's statements are therefore not competent in this regard. To the extent that these lay statements are credible, the Board finds the specific, reasoned opinion of the VA clinicians to be of greater probative weight than the Veteran's more general lay assertions. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim of service connection for a lumbar spine disability, to include as secondary to service-connected orthopedic disabilities. The benefit of the doubt doctrine is therefore not for application and the service=connection claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 3. Service connection for OSA, to include as secondary to service-connected PTSD The Veteran contends that his diagnosed OSA is due to his active military service or, in the alternative, secondary to his service-connected PTSD. Service treatment records (STRs) do not include a diagnosis, treatment, or symptoms of any sleep disorder. Post service, VA treatment records show that the Veteran was diagnosed with sleep apnea in January 2009. In his April 2010 substantive appeal, the Veteran reported that he was recently diagnosed with mild/moderate sleep apnea. He reported that he has always had sinus problems/allergies during his military career which created fatigue. His energy levels have always been questionable. He reported that he did not know that these were symptoms of sleep apnea. In a September 2015 DBQ report, a VA clinician reported that the Veteran was first diagnosed with OSA in 2009. The Veteran conveyed that this condition began in 2001. He reported problems with breathing when he slept, tossing and turning, and falling asleep while driving. The clinician found that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale for this negative nexus opinion, the clinician reported that OSA occurs due to obstruction of oropharyngeal airway in sleep. Sinus complaints, fatigue, and allergies are less likely to cause OSA. In an April 2016 lay statement, the Veteran's spouse reported that has witnessed the Veteran's poor sleeping habits, such as snoring, tossing and turning, and difficulty breathing. Also, he reported that she witnessed the Veteran falling asleep while driving his car in traffic. In an April 2016 statement from another service member, who served with the Veteran from 1999 to 2004 reported that he witnessed the Veteran's sleeping habits, including snoring; periods of not breathing; choking; and gasping for air, At the July 2016 Board hearing, the Veteran testified that in 1994, while driving in Japan, he fell asleep at the wheel in traffic. In 2000, he was traveling with a colleague and said the same thing. In a March 2017 DBQ report, a clinician indicated that the Veteran had a diagnosis of OSA. The Veteran conveyed that his ex-wife noticed excessive snoring and moments of apnea while sleeping. Also, the Veteran reported that he only slept five hours a night. The clinician opined that based on a review of the record and examination of the Veteran, it is not at least as likely as not (50 percent probability or greater) that sleep apnea incurred during service or is otherwise etiologically related to service. The clinician reported that the current diagnosis of OSA is not related to military service. As a rationale for this negative nexus opinion, the clinician reported that the claims file lacks objective medical evidence to confirm a diagnosis or treatment for OSA during military service. As such, a nexus cannot be established. He reported that sleep apnea etiology is more likely due to post-service events and is felt to be multifactorial. In a September 2020 DBQ report, a clinician opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale for this negative nexus opinion, he reported that STRs, including the examination in 2004, is silent for sleep complaints. The Veteran was diagnosed with OSA in 2009 after retirement from service. In an October 2020 addendum opinion, a clinician reported that the Veteran underwent a sleep study in 2009 which showed borderline OSA after retirement from service in 2004. The Veteran's STRs, including the retirement examination, is silent for OSA-related complaints. Although the Veteran's lay reports of somnolence, snoring, and apparent apneas in service was considered, there is still a requirement for objective evidence in STRs to establish chronicity and a relationship to service without resorting to mere speculation. The clinician reported that OSA is a chronic condition that causes chronic symptoms. A relationship cannot be established based on his lay reports alone without resorting to mere speculation given that there is simply no evidence of OSA in service and the retirement examination. In an April 2021 VA medical opinion, a clinician opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the clinician reported that OSA is less likely than not incurred in or caused by the reported daytime sleepiness during service or his reports of being told by others that he snored and gasped during sleep during service. Treatment records reflect that in January 2009 the Veteran reported his wife told him his breathing stops at night. A sleep study in April 2009 reflects that he had mild sleep apnea and moderate periodic limb movement disorder. Affidavits from March 2016 and April 2016 reported snoring/not breathing during service. This suggests that the current OSA was not incurred during service, but post-service. In other words, the Veteran was not aware that he snored or stopped breathing until his wife notified him of the events. If he were told by his fellow veterans during service, then he would have either sought medical treatment during service or immediately post-service. However, the Veteran did not seek medical treatment until 2009, 5 years later. Further, he had many opportunities during service to seek medical treatment for potential sleep disorders by the mere fact that he went to clinics for his other various medical complaints. In May 2021 correspondence, the Veteran reported that his OSA is secondary to his PTSD. He reported that current medical research has shown that depression leads to a functional decrease in serotoninergic neurotransmission. This decrease in serotonin delivery to the upper airway dilator motor neurons lead to a reduction in dilator muscle activity and pharyngeal collapsibility, in turn leading to mechanical obstruction of the upper airway. The medical treatise submitted reports that OSA can easily mimic symptoms of a major depressive episode. The majority of studies to date report an association between depression and OSA, but methodological considerations render the comparison between investigations difficult. Future longitudinal studies of patient populations are required to better understand the relation between both disorders. While the role of serotonin in mood disorders has been largely documented, its involvement in the pathophysiology of sleep apnea remains to be clarified. Although OSA and depression share common risk factors, there are currently no studies available which have investigated the issue of antecedent or consequence in the relationship between depression and OSA and metabolic syndrome. While the Board recognizes the generic value of this treatise, it contains no findings which are specific to the facts of the Veteran's medical history or clinical status. As such, the Board assigns diminished probative weight to this generic material. Guerrieri, 7 Vet. App. 467. Upon review of the evidence of record, service connection for OSA, to include as secondary to PTSD, is not warranted. As noted above, the Veteran has a current diagnosis of OSA confirmed by a sleep study. As the current disability requirement has been met, the question remains as to whether there is a nexus between the disability and service or whether his service-connected PTSD caused or aggravated his sleep apnea. The VA clinicians have all found, based on a review of the available records, their expertise, and medical literature, that the Veteran's OSA was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Specifically, the clinicians took into consideration the Veteran's statements, as well as the statements of his wife and his fellow service member. Notably, the September 2020 VA clinician explained that OSA is chronic, and the symptoms would have been seen in service. The April 2021 VA clinician noted that the Veteran was seen for many complaints during service and would have brough up difficulty sleeping as a concern during any of those times. As the clinicians explained the reasons for his conclusions based on an accurate characterization of the evidence of record, their opinions, as to the direct service connection claim, is entitled to substantial probative weight. See Nieves-Rodriguez, 22 Vet. App. 295. To the extent that the Veteran, including through his attorney, has opined that his sleep apnea is related to service and/or PTSD, lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case-by-case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson, 581 F .3d 1313. In this case, the Veteran's contentions as to the etiology of his sleep apnea relate to an internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Jandreau, 492 F. 3d 1372. For example, a lay person is competent to report daytime fatigue and observable snoring, as these are symptoms capable of lay observation. In this regard, however, the Veteran's statements regarding the etiology have been slightly inconsistent. For example, at times he has reported that his sleep apnea symptoms began in service and have continued since then. He never reported that his OSA symptoms were due to PTSD until May 2021 argument. The Veteran was not diagnosed with PTSD until 2019. He was diagnosed with OSA in 2009. The Veteran's statements are therefore not competent in this regard. To the extent that these lay statements are credible, the specific, reasoned opinions of the VA examiner are highly probative and carry greater weight than the Veteran's more general lay assertions. For the foregoing reasons, the preponderance of the evidence is against the claim for sleep apnea on a direct and secondary basis. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. B. J. KOMINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Laroche 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.