Citation Nr: 21007467 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 04-41 812 DATE: February 9, 2021 ORDER Entitlement to service connection for left knee condition is denied. Entitlement to service connection for right knee condition is denied. Entitlement to service connection for a neck disorder is denied. Entitlement to service connection for a low back disorder is denied. Entitlement to service connection for left ankle disorder is denied. Entitlement to service connection for left foot disorder is denied. Entitlement to service connection for an acquired psychiatric disorder is denied. Entitlement to service connection for bilateral eye disorder is denied. Entitlement to service connection for heart disability, to include coronary atherosclerosis as secondary to hypertension, is denied. REMANDED Entitlement to service connection for sinusitis is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that left knee condition began during active service or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that right knee condition began during active service or is otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that a neck disorder began during active service or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that a low back disorder began during active service or is otherwise related to an in-service injury or disease. 5. The preponderance of the evidence is against finding that left ankle disorder began during active service or is otherwise related to an in-service injury or disease. 6. The preponderance of the evidence is against finding that left foot disorder began during active service or is otherwise related to an in-service injury or disease. 7. The preponderance of the evidence is against finding that an acquired psychiatric disorder began during active service or is otherwise related to an in-service injury or disease. 8. The Veteran’s bilateral eye disorder is not secondary to service-connected hypertension and is not otherwise related to an in-service injury or disease. 9. The Veteran’s heart disability is not secondary to service-connected hypertension and is not otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for left knee condition are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for right knee condition are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a neck disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for a low back disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. The criteria for service connection for left ankle disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for service connection for left foot disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for service connection for an acquired psychiatric disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for service connection for bilateral eye disorder due to service or hypertension are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 9. The criteria for service connection for heart disability due to service or hypertension are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from November 1979 to May 1987 as a material storage and handling specialist. The Veteran died in June 2011. The appellant, who is the Veteran’s surviving spouse, has been substituted as the Veteran for purposes of processing the appeal to completion. 38 U.S.C. § 5121A; 38 C.F.R. § 3.1010. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2003 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). These issues were previously before the Board, most recently in December 2019, when it was remanded for VA opinions. The Board finds that there has been substantial compliance with its prior remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). The Veteran testified at a video conference hearing before a Veterans Law Judge (VLJ) in April 2007. A transcript of the hearing has been associated with the Veteran’s claims file. In an August 2019 letter, the appellant was provided notice by the Board that the VLJ who conducted that hearing was no longer employed by the Board, and that she could request another hearing before a different VLJ. In September 2019, the appellant responded that she did not wish to appear at another Board hearing and requested that the case be considered on the evidence of record. The claims file includes a January 2010 letter informing the Veteran that his service treatment records (STR) were incomplete. VA has a heightened obligation to assist the claimant in the development of their case, and to explain findings and conclusions, as well as carefully consider the benefit of the doubt rule when records in the possession of the government are lost or destroyed. See O’Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). 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). 1. Entitlement to service connection for left knee condition is denied. 2. Entitlement to service connection for right knee condition is denied. Due to a significant overlap of evidence, the claims for entitlement to service connection for left knee condition and right knee condition are considered together. The Veteran has contended that the cumulative impact of the rigors of his duties during service as a supply specialist caused continuous bilateral knee pain during service and thereafter. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of bilateral knee degenerative joint disease (DJD), and evidence shows that in-service left knee treatment occurred, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of bilateral knee DJD began during service or is otherwise related to an in-service injury, event, or disease. VA examination records show the Veteran was not diagnosed with bilateral knee DJD until January 2009, 22 years after separation from service. While the Veteran is competent to report having experienced symptoms of knee pain intermittently since service, the Veteran is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of bilateral knee DJD. The issue is medically complex, as it requires interpretation of complicated diagnostic medical testing and medical records. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Taken together, the January 2009 and June 2020 VA examiners’ opinions establish that the Veteran’s bilateral knee DJD is not at least as likely as not related to an in-service injury, event, or disease. The January 2009 VA examiner opined that the Veteran’s bilateral knee DJD was not related to events in the military, while the June 2020 VA examiner opined that the Veteran’s bilateral knee DJD was not incurred during service. The combined rationale was that there was no evidence of residuals from a 1982 in-service falling injury to his left knee, the Veteran denied knee problems at separation and the military examiner noted none, no objective evidence of problems in the year immediately after service, and current findings affected both knees symmetrically and were more consistent with aging. The examiners’ combined opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The June 2020 VA examiner expressly considered the Veteran’s contrary lay statements. Service treatment records showed treatment for left knee pain. August 1983 diagnostic imaging showed left knee effusion, but no bony abnormality. In September 1983, the Veteran underwent physical therapy for left knee pain. He reported a fall the year before and pain when running, marching, and stair-climbing. Physical examination showed “stable” knee with “good” range of motion and no effusion. The Veteran’s February 1987 Report of Medical Examination showed a “Normal” lower extremity clinical evaluation. The Veteran denied having or ever having had a “trick” or locked knee. Post-service treatment records did not document a knee-specific diagnosis until 2009, but the Veteran reported left knee problems as early as 2000 or 13 years after service. In August 2000, the Veteran reported a diagnosis of left knee arthritis to a private nephrologist. In December 2001, the Veteran sought emergency care, complaining that he could not sleep, and his knee hurt. At the April 2007 Board hearing, the Veteran report current knee symptoms, including swelling, locking, and giving out when walking or standing and he took ibuprofen. In January 2009, the Veteran underwent a VA examination. The Veteran reported that he usually had no pain in his knees, but had five out of ten pain and weakness with cold weather, medial or lateral stress, or walking a mile that increased to an eight with continued use. He also reported stiffness, swelling and left greater than right knee instability with stair climbing and fatigue when walking a mile. He reported his in-service injury as falling off a 2.5-ton truck. He reported his knee conditions prevent him from playing strenuous sports, running, or jogging, but did not prevent him from working. Physical examination showed no swelling, heat, redness, tenderness, or joint effusion. Ligaments were “stable.” Lachman, McMurray, and Baker’s cyst signs were “negative.” Range of motion testing showed 120 degrees out of a normal 140 degrees of flexion. The Veteran declined a deep knee bend and repetitive motion tests due to pain. There has “5 out of a possible 5” muscle strength, no limp, evenly worn shoes, and “no evidence of significant dysfunction of either knee.” Diagnostic imaging showed “mild” bilateral degenerative arthritis and other findings “ not associated” with the left knee joint or acute injury in the military. The VA examiner diagnosed: (1) bilateral knee symmetrical DJD consistent with normal aging not likely caused by military service, (2) no evidence of residual of injury to left knee from fall in 1982, (3) possible bone infarction of the distal left femoral metaphysis not likely caused by military service, and (4) bilateral calcific symmetrical, patellar tendonitis not likely caused by military service but consistent with normal aging. The Veteran and his spouse believe the bilateral knee DJD is related to an in-service injury, event, or disease. The Veteran and his spouse are not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of anatomical relationships and pathology and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran and his spouse in this case because the record does not show that they had the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). When the Board determines that the lay evidence is not competent, there is no need to determine whether it is credible. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Consequently, the Board gives more probative weight to the VA medical opinions. Therefore, for the reasons outlined above, the Board finds that the preponderance of evidence is against the claim of entitlement to service connection for a left knee condition and right knee condition.  As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt rule does not apply.  38 U.S.C. § 5107(b). The claims are denied. 3. Entitlement to service connection for a neck disorder is denied. 4. Entitlement to service connection for a low back disorder is denied. Due to a significant overlap of evidence, the claims for entitlement to service connection for a neck disorder and a low back disorder are considered together. The Veteran has contended that the cumulative impact of the rigors of his duties during service as a supply specialist caused a neck disorder and a low back disorder during service and thereafter. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran had current diagnoses of intermittent cervical spinal muscle spasm, mild degenerative cervical joint and disk disease, and mid-lumbar paraspinal muscle spasm, and evidence shows that the Veteran was indeed a supply specialist in the service, the preponderance of the evidence weighs against finding that the Veteran’s diagnoses began during service or are otherwise related to an in-service injury, event, or disease. VA treatment records show the Veteran was not diagnosed with intermittent cervical spinal muscle spasm, mild degenerative cervical joint and disk disease, and mid-lumbar paraspinal muscle spasm until January 2009, more than two decades after separation from service. While the Veteran is competent to report having experienced symptoms of neck and back pain intermittently since service, the Veteran is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of intermittent cervical spinal muscle spasm, mild degenerative cervical joint and disk disease, and mid-lumbar paraspinal muscle spasm. The issue is medically complex, as it requires interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Taken together, the January 2009 and June 2020 VA examiners’ opinions establish that the Veteran’s intermittent cervical spinal muscle spasm, mild degenerative cervical joint and disk disease, and mid-lumbar paraspinal muscle spasm, are not at least as likely as not related to an in-service injury, event, or disease, including as part of the Veteran’s duties as a supply specialist. The January 2009 VA examiner opined that the Veteran’s present cervical and mid-lumbar paraspinal muscle spasm was not caused by military service or events occurring within the year or years immediately following military discharge. The January 2009 VA examiner was unable to offer an opinion about degenerative cervical joint and disk disease without resorting to mere speculation. The June 2020 VA examiner found it is less likely as not that the Veteran had a neck condition due to service. The June 2020 VA examiner opined that it was less likely as not (less than 50 percent) that the Veteran had a back condition, muscle spasm, due to service. The combined rationale was that there was no objective or subjective evidence of back treatment in the military or immediately after and no subjective or objective evidence of back pain until two decades after separation. The June 2020 VA examiner found that the degenerative changes, noted in January 2009 as part of the earlier VA examination, were “mild and consistent with aging.” The examiners’ combined opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The June 2020 VA examiner expressly considered the Veteran’s contrary lay statements. Service treatment records contained reports of neck treatment, but no reports of back treatment. In October 1984, the Veteran was treated for a trapezius muscle strain four to five weeks after lifting about 125 pounds of ropes and crates. In April 1986, the Veteran reported periodic problems with a stiff neck since he began lifting weights one year prior, which was confirmed on physical examination. On a February 1987 Report of Medical History, the Veteran denied having or ever having had recurrent back or other joint pain and a clinical evaluation of the neck and spine was “normal.” At the April 2007 Board hearing, the Veteran testified that his neck and lower back conditions began in the military. The Veteran testified that he was a supply specialist, which required picking up objects and a lot of bending. He reported a stiff back, neck, and shoulders and “sharp” pain that ran into his back “a little bit.” The Veteran testified that he went on sick call for back treatment but did not have a physical profile. The Veteran testified that he had a back diagnosis in service. The Veteran also testified that he has worn a back brace, has trouble tying his shoes and raising his arms above his head, having to stop walking because of back pain, and taking ibuprofen. In January 2009, the Veteran underwent a VA examination. The Veteran reported intermittent “8 out of a possible 10” neck pain, lasting up to four hours at time and relieved by rest, not ibuprofen. The Veteran reported “a constant level 6 out of a possible 10” pain in the low back with bending, stooping, lifting, and sitting in one place or driving for more than one hour. He reported taking breaks on long drives, moving more slowly, not lifting more than 20 pounds, or walking more than 100 yards when his neck or back hurt. The pain did not radiate to legs. The Veteran reported missing two or three workdays in the last year because of neck or back pain, but no bed rest. The Veteran did not recall any trauma or injury. Lumbar spine x-ray revealed no abnormality. The VA examiner diagnosed a mid-lumbar muscle spasm. The Veteran and his spouse believe the Veteran’s intermittent cervical spinal muscle spasm, mild degenerative cervical joint and disk disease, and mid-lumbar paraspinal muscle spasm is related to an in-service injury, event, or disease. They are not competent to provide a nexus opinion regarding these issues. The issues are medically complex, as it requires knowledge of anatomical relationships and pathology and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran and his spouse in this case because the record does not show that they had the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). When the Board determines that the lay evidence is not competent, there is no need to determine whether it is credible. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Consequently, the Board gives more probative weight to the June 2020 VA medical opinion. Therefore, for the reasons outlined above, the Board finds that the preponderance of evidence is against the of entitlement to service connection for a neck disorder and a low back disorder.  As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt rule does not apply.  38 U.S.C. § 5107(b). The claims are denied. 5. Entitlement to service connection for left ankle disorder is denied. 6. Entitlement to service connection for left foot disorder is denied. Due to a significant overlap of evidence, the claims for entitlement to service connection for left ankle disorder and left foot disorder are considered together. The Veteran contends left ankle disorder and left foot disorder began during service. Alternatively, the Veteran’s representative contends that the VA examiner did not adequately consider the Veteran’s lay statements. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran had a current diagnosis of left ankle tendonitis, and evidence shows that in-service left foot treatment occurred, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of left ankle tendonitis began during service or is otherwise related to an in-service injury, event, or disease. VA treatment records show the Veteran was not diagnosed with left foot spur and calcification of big toe until August 2003, more than 16 years after separation from service. While the Veteran is competent to report having experienced symptoms of left foot and ankle pain intermittently since service, the Veteran is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of left ankle tendonitis or left foot spurring or calcification. The issue is medically complex, as it requires interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Taken together, the January 2009 and June 2020 establish that the Veteran’s left ankle disorder and left foot disorder is not at least as likely as not related to an in-service injury, event, or disease, including a falling injury. The January 2009 VA examiner opined that the Veteran’s left ankle disorder and left foot disorder was not related to military service, while the June 2020 VA examiner opined that the Veteran’s left ankle disorder and left foot disorder was not at least as likely as not related to service. The combined rationale was that the Veteran’s current condition was bilateral lower extremity peripheral neuropathy due to diabetes, which has not been service connected. The June 2020 VA examiner found that the Veteran’s 1985 left foot pain had resolved by the time of his February 1987 Reports of Medical History and Examinations and that the 1985 callous would very unlikely be mistaken by a medical professional during his service for a ganglion cyst, which the Veteran reported post-service. Diagnostic imaging in 1999 was “normal” and before developing degenerative changes consistent with aging and pain attributable to diabetic neuropathy and gout, which also has not been service connected. The examiners’ combined opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The June 2020 VA examiner expressly considered the Veteran’s contrary lay statements. Service treatment records showed treat for a left foot problem. In April 1985, the Veteran sought treatment for a left foot problem that had lasted for one week that was assessed to be a possible callus. A February 1987 Report of Medical Examination found a “normal” clinical evaluation of the Veteran’s feet and the Veteran reported no foot trouble on his medical history report. Post-service treatment records showed complaints of foot pain beginning in 1999, 12 years after service. May 1999 VA diagnostic imaging showed a “normal left foot examination.” In July 2000, a private urgent care physician assistant diagnosed diabetic neuropathy, left foot numbness. In August 2003, the Veteran reported to the VA intermittent pain and swelling in the lateral left midfoot for 20 years, exacerbated by activity and type of shoe. Physical examination showed “pink” color and no claudicating, calluses, rest pain, or loss of protective sensation. Diagnostic imaging showed a spur on the posterior aspect of the os calcis, a calcification along the medial aspect of the distal phalanx of the first toe, apparently an exostosis. The bones of foot otherwise were “unremarkable.” With no evidence of fracture or dislocation. The VA orthopedic surgeon diagnosed a ganglion cyst, left foot. At the April 2007 Board hearing, the Veteran testified that his left foot and ankle problems related to diabetes and took ibuprofen for pain. In October 2007, the Veteran sought treatment for chronic left foot pain. The Veteran reported a possible frostbite injury. Physical examination showed the Veteran was “comfortable,” gait was within normal limits, skin and neurovascular status “intact,” and no clinical abnormality of the foot while sitting. The VA orthopedic surgeon noted that the Veteran’s foot was “red, hot, & exquisitely tender suggestive of gout.” In November 2007, the Veteran reported four flareups since last visit requiring ibuprofen. Physical examination showed gait within normal limits and no clinical abnormalities. The VA orthopedic surgeon assessed a “comfortable pedal status.” A January 2008 VA diabetic foot visit show no loss of protective sensation, deformities, calluses, claudication, or rest pain. In January 2009, the Veteran underwent a VA examination. Regarding the Veteran’s left ankle, the Veteran reported left ankle and foot pain since military service. The Veteran reported a pain level “5 out of possible 10 which flares to 7” when walking one mile or climbing stair. He reported the left ankle giving way during climbing stairs or walking on uneven terrain and easy fatigability and lack of endurance. The Veteran reported jumping off the back of 2.5-ton trucks during service. The Veteran reported that the left ankle condition caused him to sit down for fifteen minutes three or four times a day but did not prevent him from working. It did prevent him from playing sports or walking more than one mile. Physical examination showed tenderness to palpation of peroneus brevis tendon, but no swelling, heat, redness, joint effusion, ganglion cyst, of the left ankle. The Veteran’s walking showed no abnormal weightbearing and shoe wear was even. Range of motion was full in dorsiflexion and plantar flexion without limitation from pain or stiffness. There was no increased pain after three repetitions or changes in range of motion with repetitive use. The VA examiner diagnosed (1) left peroneus brevis tendon calcific tendinitis not documented in the military or within the year or years immediately following military service, (2) a symptomatic calcification of the achilles tendon on the calcaneus, not likely the result of military, and (3) no evidence of left dorsal foot ganglion cyst today. Regarding the Veteran’s left foot, the Veteran reported pain confined to the proximal left lateral foot, exacerbated by standing or walking. The VA examiner attributed the pain to calcific tendinitis of the left peroneus brevis tendon. The Veteran had no weakness of the foot, but some weakness of the left ankle. The Veteran reported left ankle stiffness. The Veteran reported no symptoms in other parts of the left foot or the entire right foot. The Veteran used no assistive devices, but did wear loose, open-toed sandals to relieve pressure. The Veteran reported he could walk up to one mile and stand for one hour. Physical examination showed no evidence of painful motion, edema, instability, or weakness of either foot. Tenderness was only over the left peroneus brevis tendon. There was no tenderness anywhere else in the left or right feet. There was no evidence of calluses or broken skin. There was no unusual shoe wear, weightbearing, limp, skin or vascular changes, deformities, flat-footedness, hallux valgus. There was full range of motion. The VA examiner diagnosed (1) “mild” peripheral neuropathy of both lower extremities, particularly the feet, caused by diabetes mellitus, not the result of military service and (2) no evidence of calluses of the feet on examination today. In May 2009, the Veteran reported to a VA podiatrist left foot swelling that at times cause pain and difficulty walking since in the military. Physical examination showed no gross deformities, palpable pulses, “normal” skin, “grossly intact” neurological findings, “good” strength and tone, and “acceptable” range of motion without laxity. The VA podiatrist did find a one- by three-centimeter soft tissue along one tendon without any obvious tenderness and a “questionable” cyst. There was dorsiflexion and plantar flexion tenderness. The VA podiatrist diagnosed (1) extensor digitorum longus tendinitis, (2) possible ganglion cyst, (3) probable ostearthritis of the midfoot joints, and (3) type II diabetes mellitus. The Veteran and his spouse believe the Veteran’s left ankle disorder and left foot disorder is related to an in-service injury, event, or disease. They are not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of anatomical relationships and pathology and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran and his spouse in this case because the record does not show that they had the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). When the Board determines that the lay evidence is not competent, there is no need to determine whether it is credible. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Consequently, the Board gives more probative weight to the VA medical opinions. Therefore, for the reasons outlined above, the Board finds that the preponderance of evidence is against the Veteran’s claim for entitlement to service connection for left ankle disorder and left foot disorder.  As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt rule does not apply.  38 U.S.C. § 5107(b). The claims are denied. 7. Entitlement to service connection for an acquired psychiatric disorder is denied. The Veteran contended that a current an acquired psychiatric disorder began during active service. In November 2020, the Veteran’s representative contended that the Veteran had in-service stressors, the Veteran’s depression during the appellate period began in service, and that the Veteran attempted death by suicide in service. The question for the Board is whether the Veteran had a current disability that began during service or was at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran had a current diagnosis of depressive disorder, and evidence shows that in-service treatment for alcohol abuse occurred, the preponderance of the evidence weighs against finding that the Veteran’s current diagnosis of depressive disorder began during service or was otherwise related to an in-service injury, event, or disease. Private treatment records show the Veteran was not diagnosed with chronic major depression until April 2005, 18 years after separation from service. While the Veteran is competent to report having experienced symptoms of depression intermittently since service, the Veteran is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of depressive disorder. The issue is medically complex. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Taken together, the January 2009, July 2010, and January 2020 VA examiners’ opinions establish that the Veteran’s current depressive disorder was not at least as likely as not related to an in-service injury, event, or disease. The VA examiners opined that the Veteran’s major depressive disorder was not. The January 2009 VA examiner found that the Veteran’s reported in-service depression symptoms were related to specific stressors (mother’s death, two Article 15 disciplinary actions for drinking on duty, and pending discharge). The July 2010 VA examiner found that the Veteran did not have post-traumatic stress disorder (PTSD) and no relationship between his present complaints of mild depressed mood and alcohol abuse in 1986 because the alcohol abuse had been in remission for many years. The Veteran reported in March 2009 to a VA psychiatrist that he had stopped drinking alcohol in 1999. The January 2020 VA examiner explained that the Veteran’s in-service complaints of depressive symptoms were different than a clinical diagnosis of a depressive disorder. The January 2020 VA examiner specifically addressed the Veteran’s lay statements. The examiners’ combined opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran’s service treatment records show treatment for alcohol abuse, but no depressive disorder diagnosis. In April 1986, the Veteran spent one week in a hospital. The Veteran reported depression but was diagnosed with alcohol abuse instead. In early November 1986, he was treated for alcohol intoxication. In late November 1986, the Veteran was admitted for a third time for drinking alcohol, this time isopropyl alcohol. The treating psychiatrist assessed that this was a suicide attempt or gesture. At his February 1987 disciplinary Report of Medical Examination, the Veteran reported feeling depressed “a little” since Article 15 hearings. The examining physician recommended that the Veteran be seen for a mental health examination. Post-service treatment records show psychiatric treatment beginning 18 years after service. In April 2005, the Veteran reported to a private psychiatrist not only his in-service alcoholism, but also having nightmares about his hospitalization in a psychiatric ward. The treatment note did not include a mental status examination, but the psychiatrist did list the Veteran’s subjectively reported symptoms, including nightmares, panic attacks, intrusive thoughts, memory impairment, hearing noises, seeing shadows, and depression. The private psychiatrist diagnosed post-traumatic stress disorder (PTSD) and major depressive disorder and opined that the Veteran was unable to sustain social relationships and was “moderately” impaired from sustaining work relationships. This was his only visit with this doctor. In December 2005, VA received a statement from the Veteran’s spouse that the Veteran had current nightmares about being in the psychiatric ward in service. At the April 2007 Board hearing, the Veteran reported that he was diagnosed with depression during service. As noted above, there is otherwise no other record of it. In January 2009, the Veteran underwent a VA examination. The Veteran reported a pre-military history of drinking since age 13, military history including two Article 15 disciplinary actions for drinking on duty and 1986 hospitalization and depression complaints, and post-military history of a 1998 death by suicide attempt and two driving under the influence arrests. The Veteran reported current depression symptoms, three days during the previous week, four to five minutes each day. Mental status examination showed “clean” appearance, “unremarkable” psychomotor activity, speech, and thought process, “intact” orientation, but “constricted” affect, “suspiciousness” thought content, “bizarre” delusions, partial insight, and visual hallucinations. A malingering test indicated that the Veteran may be malingering mental illness. The VA examiner diagnosed depression not otherwise specified and found the Veteran’s symptoms were not severe enough to interfere with occupational and social functioning. In March 2009, the Veteran reported “new onset” depression with nightmares, anxiety, and suicidal thoughts, but stated he was functioning “OK.” The Veteran reported a history of feeling depressed beginning and since service to a VA psychiatrist. He reported symptoms of lack of sleep, low interest, guilt, low energy, poor concentration, restlessness, irritability, and muscle tension. He reported an additional 1994 attempt of death by suicide. A December 2012 VA depression screen, however, was negative. A mental status examination showed a “quiet, guarded” appearance, alert and oriented to person, place, and time, “ok” mood, “WNL” psychomotor, “normal” speech, “linear and goal-directed” thought process, “intact” cognition, insight, and judgment, and he denied suicidal or homicidal thought or delusions, but “restricted” affect and “occasional” voices. The VA psychiatrist diagnosed depression not otherwise specified and prescribed medication. In April 2009, the Veteran reported feeling “very depressed” and the above medical history to a VA psychiatrist. Mental status examination showed that he was oriented, had “intact” cognition, and he denied suicidal or homicidal thought or delusions, but had “mildly flat” affect, “slight” psychomotor slowing, and “vague” paranoia and he reported hearing voices. The VA psychiatrist diagnosed recurrent moderate major depressive disorder and alcohol and nicotine dependence in remission. The VA psychiatrist adjusted the Veteran’s medications and assessed that the Veteran was “stable and not suicidal,” “able to express himself fairly well,” “not psychotic,” and “fairly functional and working regularly.” In July 2010, the Veteran underwent another VA examination. The Veteran reported an unchanged medical history and current symptoms of a “low” mood, lack of interest, and “mild” depression. A mental status examination showed a “clean” appearance, “cooperative” attitude, “intact” attention and orientation, “unremarkable” thought process and content, but “lethargic” psychomotor activity, “constricted” affect. He reported no particularly traumatic in-service stressors but found his psychiatric hospitalization “undesirable” and the VA examiner found testing data “inconsistent” with a diagnosis of PTSD. The VA examiner diagnosed depression not otherwise specified and found the Veteran’s symptoms were not severe enough to interfere with occupational and social functioning. The Veteran and the Veteran’s spouse believed that the Veteran’s depressive disorder was related to an in-service injury, event, or disease. The Veteran and the Veteran’s spouse in this case were not competent to provide a nexus opinion regarding this issue. The issue is medically complex. Therefore, it is outside the competence of the Veteran and the Veteran’s spouse in this case because the record does not show that they had the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Credibility is a factual determination as to whether a witness is worthy of belief. The weight, or probative value, of evidence is a factual determination as to the tendency of the evidence to establish the proposition that it is offered to prove. While the credibility of a witness may speak towards the probative value of his or her statements, they are still separate analyses. Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The absence of supporting evidence does not, in and of itself, impugn a witness’s credibility, i.e., make that person not worthy of belief, but it is something the Board may consider in weighing evidence. Barr v. Nicholson, 21 Vet. App. 303 (2007) (post-service gap in complaints). The credibility of a witness can be impeached by a showing of inconsistent statements. Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff’d per curiam, 78 F.3d 604 (Fed. Cir. 1996). Here, the Boards finds inconsistencies in the record that reduce the probative value of the otherwise credible subjective lay statements from the Veteran. For example, the January 2020 VA examiner found following information was inconsistent with the Veteran’s report of continuous depression since the military: A) Results from a December 2008 VA depression screening reflected that the Veteran denied experiencing depression; B) The Veteran’s depression was reported to be in remission on medication by his VA psychiatrist in a September 2009 treatment note; and C) An April 2009 VA psychiatry note referred to a new onset of depression. This suggests that the depression was in remission prior to this. Therefore, even if the Board took the Veteran’s assertion that he had an in-service depression diagnosis at face value, the Board cannot ignore that the January 2020 VA examiner found medical reasons to reject the proposition that the Veteran’s reported symptoms after service represented the onset of the Veteran’s current depression. The Board does not find a preponderance of evidence to support that the Veteran has had continuous symptoms of depression ever since military service. Consequently, the Board gives more probative weight to the January 2020 VA medical opinion that the Veteran’s subjective lay statements. Therefore, for the reasons outlined above, the Board finds that the preponderance of evidence is against the Veteran’s claim for entitlement to service connection for an acquired psychiatric disorder.  As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt rule does not apply.  38 U.S.C. § 5107(b). The claim is denied. 8. Entitlement to service connection for bilateral eye disorder is denied. The Veteran contended that the Veteran had a bilateral eye disorder that began in service. Alternatively, the Veteran’s spouse’s representative contends that the Board should not grant more weight to the three most recent VA negative nexus medical opinions than the earliest VA medical opinion that did find that the Veteran’s glaucoma began in service. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnoses of glaucoma and dry eyes, and evidence shows that in-service left eye injury occurred, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of glaucoma and dry eyes began during service or is otherwise related to an in-service injury, event, or disease. VA examination records show the Veteran was not diagnosed with suspected glaucoma until 2000, more than ten years after separation from service. While the Veteran is competent to report having experienced symptoms since service, the Veteran is not competent to provide a diagnosis in this case or determine that these symptoms were manifestations of glaucoma and dry eyes. The issue is medically complex. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The record contains conflicting medical opinions regarding whether the Veteran’s glaucoma is at least as likely as not related to an in-service injury, event, or disease. Three VA examiners opined that it was not. Taken together, the April 2010, May 2010, and June 2020 VA examiners’ opinions establish that the Veteran’s glaucoma and dry eyes are not at least as likely as not related to an in-service injury, event, or disease. The June 2020 VA examiner opined that neither the Veteran’s glaucoma nor dry eyes were caused by nor related to service and less likely as not caused by or related to hypertension. The May 2010 VA examiner opined that the Veteran’s the glaucoma was not caused by nor related to military service. The April 2010 VA examiner opined that neither the Veteran’s glaucoma nor dry eyes were caused by nor related to service. The combined rationale was that there was no indication of suspected glaucoma documented in the Veteran’s service treatment records. The Veteran was treated for a corneal abrasion in service, but corneal abrasion had resolved without residuals during service and corneal abrasions do not cause glaucoma. The suspected glaucoma first appeared in 2000 and there was no record of the corneal abrasion after service. Review of medical literature did not indicate a cause and effect relationship between hypertension and glaucoma and dry eyes are caused by poor tear production or quality, not hypertension. The examiners’ combined opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). One VA examiner opined that it was. The rationale was that the suspected glaucoma was a “progressive condition that has remained stable with treatment since separation.” This opinion is, however, less probative than the VA examiner’s opinion. The January 2009 VA examiner did not have access to as much of the pertinent medical evidence in the claims file as did the later VA examiners. Instead, the opinion appears to be based on inaccurate information, which is inconsistent with treatment records that show that the suspected glaucoma first appeared in 2000 or 13 years after separation. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Consequently, the Board gives more probative weight to the June 2020 VA examiner’s opinion. Service treatment records show eye treatment. In April 1987, the sought treatment one week after being poked by a finger in the left eye. The Veteran reported discomfort and a foreign body sensation. There was no eyelid edema, discharge, or conjunctival erythema. The treating physician diagnosed corneal abrasion. Post-service treatment records showed treatment for glaucoma more than ten years after service. In October 2000, the Veteran sought treatment for diabetes at a VA eye clinic and was assessed with suspected glaucoma. At the April 2007 hearing, the Veteran testified that his eye problems began in service, was first diagnosed in 1998, but guessed that it was due to his hypertension. The Veteran was asked twice by his representative but did not recall an in-service eye injury. This was again noted in June 2002 by a VA optometrist. In January 2009, the Veteran underwent a VA examination. The Veteran reported redness, burning or stinging, watering, blurring, and glare. Slit lamp and fundoscopic examination were “abnormal.” The VA examiner diagnosed (1) glaucoma, (2) diabetes mellitus without retinopathy, (3) corneal abrasion, healed without sequelae, and (4) presbyopia. In April 2010, the Veteran underwent another VA examination. The Veteran reported glare, blurring, and floaters. The Veteran report no incapacitating episodes. Slit lamp and fundoscopic examination were “abnormal.” The VA examiner diagnosed (1) mild dry eyes, (2) open angle glaucoma, and (3) diabetes mellitus without retinopathy. The Veteran and his spouse believe the Veteran’s glaucoma and dry eyes is related to an in-service injury, event, or disease. They are not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge pathology and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran and his spouse in this case because the record does not show that they had the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). When the Board determines that the lay evidence is not competent, there is no need to determine whether it is credible. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Consequently, the Board gives more probative weight to the June 2020 VA medical opinion. Therefore, for the reasons outlined above, the Board finds that the preponderance of evidence is against the Veteran’s claim for entitlement to service connection for bilateral eye disorder.  As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt rule does not apply.  38 U.S.C. § 5107(b). The claim is denied. 9. Entitlement to service connection for heart disability, to include coronary atherosclerosis as secondary to hypertension, is denied. The Veteran’s spouse’s representative contends that the Veteran’s heart disability was related to service-connected hypertension. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board’s adjudication will consider only entitlement to secondary service connection. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran had a current disability that is proximately due to or the result of or was aggravated beyond its natural progress by service-connected disability. The Board concludes that, while the Veteran died of severe coronary atherosclerosis, the preponderance of the evidence is against finding that the Veteran’s severe coronary atherosclerosis is proximately due to or the result of or aggravated beyond its natural progression by 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 January 2009 VA examiner opined that his current reported midsternal chest wall pain, exacerbated by coughing spasms, is not caused by any condition occurring or diagnosed in the military or within one year of military discharge. The June 2020 VA examiner opined that the Veteran’s death was instead more likely due to sudden cardiac arrest, respiratory arrest, and pulmonary edema. The rationale was that the Veteran did not have a heart disability diagnosis. The VA examiner found that the Veteran’s last blood pressure reading, taken in December 2010, was “well controlled” and reported as 125/80. The VA examiner explained that the Veteran met at least five other risk factors for cardiac arrest, including being male, obesity, smoking, diabetes, and high cholesterol. The VA examiner opined that it was less likely as not that the Veteran had a heart disability related or aggravated by service-connected hypertension. 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). Service treatment records did not document a heart disability. In March 1984, the Veteran was treated for musculoskeletal chest pain. The Veteran reported five weeks of discomfort in his chest usually while working, running, or other exertion and localized to a size of less than a quarter. The discomfort was sharp and goes away after two to four minutes after he stops what he was doing. He denied shortness of breath. He reported smoking, but no hypertension. He was also treating for alcohol abuse. Physical examination showed that the Veteran was in no acute distress, 115/82 blood pressure, clear respiration, regular heart rhythm, but tensing his pectoral muscles reproduced pain. An electrocardiogram was “normal.” The treating internal medicine physician found his musculoskeletal chest pain “extremely unlikely to be cardiac” related. He was given a physical profile for a pectoralis muscle strain to do physical training at his own pace and no pushups. In February 1985, the Veteran’s blood pressure was 126/100, 128/100, and 130/102. November 1986 diagnostic imaging showed “the cardiac silhouette to be WNL and the lung parenchyma to be clear.” February 1987 Report of Medical Examination showed a “normal” clinical evaluation of the heart. Chest imaging was within normal limits. The Veteran did not report any heart trouble. Post-service treatment records also did not show a heart disability. February 1998 private imaging showed a “normal radiographic examination of the chest.” March 2000, 13 years after separation, imaging taken after workplace exposure to ammonia showed “possibly slight enlargement of the cardiac silhouette,” but an electrocardiogram showed a “normal sinus rhythm.” August 2000 private chest imaging showed “no active cardiopulmonary disease.” In December 2001, the Veteran sought private urgent care for chest pain. His blood pressure was 159/100 around 9:15pm, but by 10:15pm the Veteran reported feeling “100% better.” At 10:40pm, the Veteran was not in his room and could not be found and apparently had left wearing his intravenous tube, leaving his telemetry leads and oxygen tubes behind in his room. At the April 2007 Board hearing, the Veteran testified that he had sharp pain within his chest when lifting and moving left to right. He affirmed that he was told in the service that his heart was okay but also that he did have shortness of breath over the years. In January 2009, the Veteran underwent a respiratory VA examination. The Veteran reported chest pain in midsternal region rather than pectoralis muscle. The Veteran also reported cough spasms, more frequent during pollen season. He reported that he did not have shortness of breath after walking one mile and that ibuprofen did not relieve pain. Physical examination showed “well developed” chest muscles, no tenderness, full chest wall excursion, no wheezes or crackles, “normal” heart sounds with no murmur or gallop, and “regular” pulse. The Veteran’s blood pressure was 130/80. The VA examiner diagnosed (1) atypical chest pain, not similar or localized to the area of that diagnosed in the military and (2) chemical pneumonitis from episode of ammonia inhalation as a civilian has resolved. In June 2011, the Veteran died. His death certificate listed “severe coronary atherosclerosis.” The Veteran and his spouse believe the Veteran’s heart disability was proximately due to or the result of a service-connected disability. They are not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of pathology and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran and his spouse in this case because the record does not show that they had the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). When the Board determines that the lay evidence is not competent, there is no need to determine whether it is credible. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Consequently, the Board gives more probative weight to the VA medical opinion. Therefore, for the reasons outlined above, the Board finds that the preponderance of evidence is against the Veteran’s claim for entitlement to service connection for heart disability.  As the preponderance of the evidence weighs against the claim, the benefit-of-the-doubt rule does not apply.  38 U.S.C. § 5107(b). The claim is denied. REASONS FOR REMAND Entitlement to service connection for sinusitis is remanded. Unfortunately, the June 2020 VA medical opinion is inadequate. The opinion did not consider all the relevant evidence of record, including lay statements. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Dalton v. Nicholson, 21 Vet. App. 23 (2007). The June 2020 VA examiner declined to provide a medical opinion because, according to the VA examiner’s review, treatment records from September 1999 to June 2011 “are all silent for the diagnosis of or treatment for acute, recurrent, or chronic sinusitis.” This statement, however, directly contradicts the January 2009 VA examination report, which included a diagnosis of “mild left frontal and maxillary sinusitis” and diagnostic imaging that showed “moderate cloudiness over the left maxillary sinus and frontal sinus.” An adequate addendum VA medical opinion addressing this inconsistency is warranted. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). There also has not been substantial compliance with the Board’s previous remand directives regarding the issue of entitlement to service connection for sinusitis. In its December 2019 remand, the Board ordered the VA examiner to address the Veteran’s competent report of continuous sinusitis symptoms in the years since service. The June 2020 VA examiner, however, did not address the Veteran’s lay statements. At the April 2007 Board hearing, the Veteran testified that his sinus problems began in the military and he was healthy before that. He testified that he had sought treatment for what he thought were migraine headaches and was diagnosed with sinusitis in the service and was given medication to relieve pressure and still takes such medication. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matter is REMANDED for the following actions: Obtain an addendum opinion concerning the cause of the Veteran’s sinus disorders. The claims file, including a copy of this remand order, must be made available for review. Is it at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran’s diagnosed sinus disorder, to include sinusitis and rhinitis, had its onset in service or is otherwise related to active duty service, to include the Veteran’s report of experiencing symptoms of nasal congestion and sinusitis during active duty service? In addressing this question, the examiner must address the Veteran’s competent report of continuous sinusitis symptoms in the years since service. See February 1987 Report of Medical History; April 2007 Board Hearing at 13, January 2009 VA examination report. The examiner should note that the Veteran’s complete service treatment records have been found by VA to be unavailable. Thus, the absence of evidence of treatment in the Veteran’s service treatment records or in the records following service separation cannot, standing alone, serve as the basis for a negative opinion. Please state whether there is any medical reason for rejecting the Veteran’s statements. A complete rationale must be provided for all opinions expressed. If the examiner is unable to provide an opinion without resorting to speculation, an explanation as to why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered should be provided. Merely saying he or she cannot respond will not suffice. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion below. The examiner is asked to provide a response to the following: Is sinusitis at least as likely as not related to service? Provide a rationale to support the opinion. At the April 2007 Board hearing, the Veteran testified that his sinus problems began in the military and he was healthy before that. He testified that he had what he thought were migraine headaches and was diagnosed with sinusitis and was given medication to relieve pressure and still take such medication. In providing the requested opinion, consider the Veteran’s description of in-service symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury and symptoms in service and thereafter represented the onset of current disability, this should be noted. Stated another way, do the Veteran’s reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran’s reports generally inconsistent with medical knowledge or implausible? G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James Hekel, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.