Citation Nr: 21014562 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 14-00 208 DATE: March 15, 2021 ORDER Entitlement to service connection for a low back disability is denied. Entitlement to service connection for right lower extremity radiculopathy is denied. Entitlement to service connection for left lower extremity radiculopathy is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for psoriatic arthritis is denied. Entitlement to service connection for a liver disability is denied. Entitlement to service connection for a psychiatric disorder is denied. Entitlement to service connection for a circulatory disorder is denied. FINDINGS OF FACT 1. The Veteran’s low back disability, currently diagnosed as left posterolateral herniated disc at L5-S1 impinging on the left S1 nerve root/lumbar spine degenerative disc disease, was not manifest in service, is unrelated to service, and is not caused or aggravated by his service connected ankle disabilities. 2. The Veteran’s current right and left lower extremity radiculopathy was not manifest in service or to a degree of 10 percent within one year of separation, is unrelated to service, and was not caused or aggravated by his service connected ankle disabilities. 3. The Veteran’s current right and left knee disabilities, currently diagnosed as bilateral patellofemoral syndrome with a small right knee effusion; and osteoarthritis; were not manifest in service or, for arthritis, to a degree of 10 percent within one year of separation, are unrelated to service, and were not caused or aggravated by his service connected ankle disabilities. 4. The Veteran’s current psoriatic arthritis was not manifest in service or to a degree of 10 percent within one year of separation, is unrelated to service, and was not caused or aggravated by his service connected ankle disabilities. 5. The Veteran’s liver disability, currently diagnosed as fatty liver disease, which was not manifest in service, is unrelated to service, and was not caused or aggravated by his service connected ankle disabilities. 6. The Veteran’s psychiatric disorders, currently diagnosed as major depression and unspecified anxiety disorder, were not manifest in service, are unrelated to service, and were not caused or aggravated by his service connected ankle disabilities. 7. The Veteran’s circulatory disorder, currently diagnosed as lower extremity venous insufficiency, was not manifest in service, is unrelated to service, and was not caused or aggravated by his service connected ankle disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for service connection for right lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for left lower extremity radiculopathy have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 4. The criteria for service connection for right knee disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 5. The criteria for service connection for a left knee disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 6. The criteria for service connection for psoriatic arthritis have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 7. The criteria for service connection for a liver disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. 8. The criteria for service connection for a psychiatric disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. 9. The criteria for service connection for a circulatory disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1994 to July 1994 from February 2003 to May 2003. The Board thanks him for his service. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a September 2010 rating decision issued by a Regional Office the Department of Veterans Affairs (VA). The above matters were before the Board in July 2018 and April 2020, when they were remanded for additional development. They now return for appellate review. Additional evidence was submitted by the Veteran in February 2021, subsequent to the most recent February 2021 supplemental statement of the case issued for the appeal herein. The Veteran did not waive Agency of Original Jurisdiction (AOJ) review of this additional evidence. However, if new evidence is submitted with or after a substantive appeal received on or after February 2, 2013, then it is subject to initial review by the Board unless the appellant explicitly requests AOJ consideration. Here, the Veteran’s substantive appeal for this appeal was filed after February 2, 2013, and the Board interprets such exception as applying only to evidence submitted by the Veteran. As described above, the record reflects the entirety of the additional evidence was submitted by the Veteran, thus a remand for AOJ consideration is not warranted. Service Connection Establishing service connection generally requires medical or, in certain circumstances, lay evidence of: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). Service connection may be awarded on a presumptive basis for certain chronic diseases listed in 38 C.F.R. § 3.309(a) that manifest to a degree of 10 percent within one year of service separation or during service and then again at a later date. 38 C.F.R. §§ 3.303(b), 3.307; see Walker v. Shinseki, 708 F.3d 1331, 1337 (Fed.Cir.2013). Arthritis and organic disease of the nervous system are listed as chronic diseases. Evidence of continuity of symptomatology may be sufficient to invoke this presumption if a claimant demonstrates (1) that a condition was “noted” during service; (2) evidence of post service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post service symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (citing Savage v. Gober, 10 Vet. App. 488, 496–97(1997)); see 38 C.F.R. § 3.303(b). Service connection may be granted, on a secondary basis, for a disability which is proximately due to, or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Similarly, any increase in severity of a non-service connected disease or injury that is proximately due to or the result of a service connected disease or injury, and not due to the natural progress of the nonservice connected disease, will be service connected. Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the non-service connected disease or injury is said to have been aggravated by the service-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for a low back disability Based on the evidence, the Board concludes that service connection is not warranted for the Veteran’s current low back disability, which the evidence, including May 2010, June 2019, September 2020, December 2020, and January 2021 VA examination reports, reflects is currently diagnosed as left posterolateral herniated disc at L5-S1 impinging on the left S1 nerve root/lumbar spine degenerative disc disease. The preponderance of the evidence indicates that the Veteran’s low back disability was not manifest in service and is unrelated to service. Specifically, review of the Veteran’s service treatment records does not reflect a low back injury, or related complaints. Further, in May 2010, the Veteran indicated that he first developed strong low back pain, associated with stiffness, in around 2004, which was post-service, and that he had had no treatment for it until 2009, at which time, a MRI found a herniated nucleus pulposus. Moreover, a June 2019 VA examiner concluded that the Veteran’s low back disability was less likely than not related to service, indicating that it was diagnosed several years post-service and was due to the Veteran’s normal aging process. The preponderance of the evidence, including May 2010, June 2019, and September 2020 VA examination reports, also indicates that the Veteran’s low back disability was not caused or aggravated by his service connected right or left ankle disability. Specifically, the May 2010 VA examiner explained that Veteran’s low back disability was not caused by his service connected right ankle disability because they were different disease entities with different pathophysiological processes unrelated to each other, and the Veteran’s right ankle joint was stable and had a full range of motion with normal strength and no edema or effusion. A June 2019 VA examiner found the Veteran’s degenerative disc disease was less likely than not related to service-connected bilateral ankle conditions. As a rationale, the June 2019 VA examiner explained the medical evidence did not support the fact that having ankle strain and residual, right ankle avulsion fractures, status post immobilization, could possibly cause degenerative disc disease of the lumbar spine as these conditions were completely unrelated to each other anatomically and by pathophysiology. As to aggravation, the September 2020 VA examiner found the Veteran’s lumbar degenerative disc disease was less likely than aggravated beyond its natural progression by his service-connected disabilities, including right and left ankle disabilities. As a rationale, the September 2020 VA examiner explained, in part, these were different disease entities with different pathophysiological process unrelated to each other without biomechanical interaction. Conversely, Dr. Ortiz Valentin opined in July 2011 that it was more probable than not that the Veteran’s back problems were due to his left ankle problem. However, Dr. Ortiz Valentin’s opinion is inconsistent with the Veteran’s post service medical evidence as she reported that due to chronic pain from the Veteran’s right ankle problem, he started to bear weight to the other side of his body, and that this caused problems of bad posture and loss of correct alignment of the lumbar lordosis. However, there is little support for this in the record, and to the contrary, as recently as January 2021, the Veteran presented with a normal gait pattern with no antalgic gait and no weight shifting during ambulation. Thus, Dr. Ortiz Valentin’s opinion is inconsistent with the other evidence of record, and thus, lacks probative value. Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Additionally, as to the Veteran’s submission in February 2021 concerning antalgic gait in adults, this submission provided medical information that was general in nature, and did not address the specifics of the Veteran’s case. Rather, the VA opinions, discussed above, considered the specific facts related to the Veteran’s case in conjunction with his medical history which far outweighed the generalities of the article submitted. Libertine v. Brown, 9 Vet. App. 521 (1996). Thus, based on the reasons and bases discussed, the preponderance of the evidence is against the claim, and the benefit of the doubt rule is inapplicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Accordingly, service connection is not warranted for a low back disability. 2. Entitlement to service connection for right lower extremity radiculopathy 3. Entitlement to service connection for left lower extremity radiculopathy Based on the evidence, the Board concludes that service connection is not warranted for the Veteran’s current right and left lower extremity radiculopathy, shown in his medical records, including most recently in a January 2021 VA examination report. The preponderance of the evidence indicates that this did not manifest in service or to a degree of 10 percent within one year of separation and is unrelated to service. Specifically, review of the Veteran’s service treatment records does not reflect a diagnosis, or related complaints. Rather, it was first shown years post-service, with the Veteran being shown to have a left posterolateral herniated disc in May 2010 and numbness of the thighs felt to be most likely related to radiculopathy at the lumbar region in January 2011. The complaints in May 2010 were of back pain since around 2004, with the first treatment in 2009, and radiculopathy is shown after this. The VA examiner in January 2021 opined that the condition claimed was less likely than incurred in or caused by the claimed in-service injury, event or illness. As a rationale, the January 2021 VA examiner explained that the Veteran’s service treatment records were silent for such disability and that lumbar disc disease with radiculopathy was a chronic condition that tends to progressively worsen over time with the natural aging process and/or due to repetitive trauma. The preponderance of the evidence, including the September 2020 and January 2021 VA examination reports, also reflects that the Veteran’s current lower extremity radiculopathy was not caused or aggravated by his service connected ankle disabilities. As a rationale for the opinion proffered specific to aggravation, the September 2020 VA examiner indicated that the Veteran’s radiculopathy had followed a normal progression, and so it could not have been aggravated by his service connected ankle disabilities. As a rationale for the opinion proffered as proximately due to or the result of the Veteran’s service connected condition, the January 2021 VA examiner indicated that it was not caused by the Veteran’s service connected ankle disabilities because they were not related pathophysiologically or anatomically to each other, and because the Veteran presented with a normal gait pattern with no antalgic gait and no weight shifting during ambulation. Thus, based on the reasons and bases discussed, the preponderance of the evidence is against the claims, and the benefit of the doubt rule is inapplicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49, 54-56 (1990). Accordingly, service connection is not warranted for right lower extremity radiculopathy and left lower extremity radiculopathy. 4. Entitlement to service connection for a right knee disability 5. Entitlement to service connection for a left knee disability Based on the evidence, the Board concludes that service connection is not warranted for the Veteran’s current right and left knee disability, which the evidence, including a May 2010 VA examination report, April 2016 private radiographic reports, and a September 2020 VA examination report, indicates are bilateral patellofemoral syndrome with a small right knee effusion and osteoarthritis. The preponderance of the evidence indicates that these were not manifest in service or, for arthritis, to a degree of 10 percent within one year of separation, and that they are unrelated to service. Specifically, review of the Veteran’s service treatment records does not reflect a diagnosis of either knee, or related complaints. Instead, a knee disability was first shown years post-service, with the Veteran indicating in May 2010 that knee pain started five years prior and that he had had his first treatment in 2009. Further, the June 2019 VA examiner opined that the condition claimed was less likely than not incurred in or caused by the claimed in-service injury, event or illness. As a rationale, the June 2019 VA examiner explained the bilateral knee condition was diagnosed several years after service and was due to the normal progression of the aging process. Similarly, a January 2021 VA examiner opined that the condition claimed was less likely than not incurred in or caused by the claimed in-service injury, event or illness. As a rationale, the January 2021 VA examiner noted the Veteran’s service treatment records were silent for the condition claimed. The January 2021 VA examiner also explained the Veteran’s knee conditions were diagnosed by imaging studies several years post-service and there was no evidence of continuity of treatment (nor of documented knee problems) for at least five years after service discharge. Also, the January 2021 VA examiner noted medical literature supports the fact that knee osteoarthritis is considered part of the normal aging process in patients, such as the Veteran, who are older than 35 to 45 years old. The preponderance of the evidence including May 2010, June 2019, September 2020, and January 2021 VA examination reports also indicates that the Veteran’s bilateral knee disability were not caused or aggravated by his service connected ankle disabilities. In this regard, the May 2010 VA examiner explained that Veteran’s low back disability was not caused by his service connected right ankle disability because they were different disease entities with different pathophysiological processes unrelated to each other, and the Veteran’s right ankle joint was stable and had a full range of motion with normal strength and no edema or effusion. This would apply to the Veteran’s left ankle disability as well. The June 2019 VA examiner found the Veteran’s bilateral knee condition was less likely than related to his service-connected bilateral ankle condition. As a rationale, the June 2019 VA examiner explained the evidence did not support the fact that having an ankle strain and an ankle fracture could possibly cause degenerative arthritis at the knee joints and as these conditions were completely unrelated to each other anatomically and by pathophysiology. As to aggravation, a September 2020 VA examiner found the Veteran’s right and left knee degenerative joint arthritis was less likely than aggravated beyond its natural progression by his service-connected disabilities, including right and left ankle disabilities. As a rationale, the September 2020 VA examiner explained, in part, these were different disease entities with different pathophysiological process unrelated to each other without biomechanical interaction. The September 2020 VA examiner also noted a lack of clinical and objective evidence to support that the knee conditions were aggravated beyond their natural progress and that these disabilities dated to years after service and had followed a natural progression. The January 2021 VA examiner opined that the conditions were less likely than not proximately due to the service connected ankle disabilities because the knees and ankles are not pathophysiologically or anatomically related to each other, and because the Veteran had a normal gait pattern, with no antalgic gait or weight shifting during ambulation. While May 2019 correspondence from Dr. Espina indicated that ankle disabilities could cause or aggravate lower extremity and back problems, a ‘may or may not’ opinion such as this is not probative. See Tirpak v. Derwinski, 2 Vet. App. 609, 611 (1992) and ZN v. Brown, 6 Vet. App. 183 (1994). Also, Dr. Ortiz Valentin opined in July 2011 that it was likely that the Veteran’s knee problems were connected to his left ankle problem. However, her rationale in support of this, was that the Veteran started to bear his weight to the other side of his body after an in service right ankle injury, and that this caused pressure and strain on his knees. However, there is little support for this in the record, and to the contrary, as recently as January 2021, the Veteran presented with a normal gait pattern with no antalgic gait and no weight shifting during ambulation. Thus, Dr. Ortiz Valentin’s opinion is inconsistent with the other evidence of record, and thus, lacks probative value. Reonal, 5 Vet. App.at 460-61. Additionally, as to the Veteran’s submission in February 2021 concerning antalgic gait in adults, this submission provided medical information that was general in nature, and did not address the specifics of the Veteran’s case. Rather, the VA opinions, discussed above, considered the specific facts related to the Veteran’s case in conjunction with his medical history which far outweighed the generalities of the article submitted. Libertine, 9 Vet. App. at 523. Thus, based on the reasons and bases discussed, the preponderance of the evidence is against the claim, and the benefit of the doubt rule is inapplicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49, 54-56 (1990). Accordingly, service connection is not warranted for right knee disability and left knee disability. 6. Entitlement to service connection for psoriatic arthritis Based on the evidence, the Board concludes that service connection is not warranted for the Veteran’s current psoriatic arthritis. The preponderance of the evidence indicates that it was not manifest in service and is unrelated to service. Specifically, review of the Veteran’s service treatment records does not reflect a diagnosis of psoriatic arthritis, or related complaints. Further, post-service, a January 2009 private medical record indicated that the Veteran complained of a rash of his scalp, face, back, and legs. Clinically, he had scaly mildly erythematous patches on his face, scalp, extremities, and ears; and erythematous plaques down his back and the impression was rule out psoriaform dermatitis. Psoriatic arthritis was later assessed, including in September 2010, and December 2020 VA examination reports documented it in multiple joints. The preponderance of the evidence also indicates that the Veteran’s psoriatic arthritis was not caused or aggravated by his service connected disabilities, including through obesity purportedly caused by them. A December 2020 VA medical opinion indicates that the medical literature does not support a cause or aggravation of the joints. The December 2020 VA examiner indicated that obesity occurs when people take in more calories than they burn through exercise and normal daily activities and their bodies store these excess calories as fat, and typically diets are too high in calories. The December 2020 VA examiner explained that although the Veteran may be limited in certain exercises such as running, there are other exercises that can be done to burn off calories, as well as limitations of intake based on activities. Thus, the Veteran’s claim of psoriatic arthritis is less likely than not secondary to or aggravated by his service connected bilateral ankle disabilities, including as due to obesity. Additionally, the December 2020 VA examiner indicated that a baseline level of severity of right and left ankle psoriatic arthritis disability prior to any aggravation by the service-connected right and left ankle disabilities could not be determined, because the medical evidence is insufficient to determine this. Under 38 C.F.R. § 3.310, VA will not concede that a nonservice-connected disease or injury was aggravated by a service connected disability unless the baseline level of severity of the non service connected disease or injury is established by medical evidence. Thus, based on the reasons and bases discussed, the preponderance of the evidence is against the claim, and the benefit of the doubt rule is inapplicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49, 54-56 (1990). Accordingly, service connection is not warranted for psoriatic arthritis. 7. Entitlement to service connection for a liver disability Based on the evidence, the Board concludes that service connection is not warranted for the Veteran’s current liver disorder, which the evidence, including an April 2010 VA medical record, indicates is fatty liver disease (also known as hepatic steatosis). The preponderance of the evidence indicates that it was not manifest in service and is unrelated to service. Specifically, review of the Veteran’s service treatment records does not reflect a diagnosis as to liver disability, or related complaints, and such disability was not shown until years post-service. In this regard, a March 2010 private abdominal sonogram provided that findings were consistent with diffuse fatty liver, and an April 2010 VA medical record reported an assessment of fatty liver secondary to obesity, with weight loss being the only treatment option. The preponderance of the evidence also indicates that the Veteran’s fatty liver disease was not caused or aggravated by his service connected disabilities, including through obesity. The December 2020 VA examiner indicated that obesity occurs when people take in more calories than they burn through exercise and normal daily activities and their bodies store these excess calories as fat, and typically diets are too high in calories. The December 2020 VA examiner explained that although the Veteran may be limited in certain exercises such as running due to his service connected ankle disabilities, there are other exercises that can be done to burn off calories, as well as limitations of intake based on activities. The Veteran’s claim of obesity and thus fatty liver disease is less likely than not secondary to or aggravated by his service connected bilateral ankle disabilities. The December 2020 VA examiner also opined that the Veteran’s fatty liver disease was not caused or aggravated by medications taken for his service connected ankle disabilities. As a rationale, the VA examiner cited to medical literature which indicates that fatty liver is related to, caused by, or aggravated beyond its normal progression by obesity. The December 2020 VA examiner indicated that fatty liver disease would not be related to, caused by, or aggravated beyond its normal progression by medications taken for the ankle disabilities. Thus, based on the reasons and bases discussed, the preponderance of the evidence is against the claim, and the benefit of the doubt rule is inapplicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49, 54-56 (1990). Accordingly, service connection is not warranted for a liver disability. 8. Entitlement to service connection for a psychiatric disorder Based on the evidence, the Board concludes that service connection is not warranted for the Veteran’s current psychiatric disorders, which the evidence, including a May 2016 VA examination report and an August 2020 VA medical opinion, indicates are major depression due to laboral and financial stressors, with sentinel events being dysfunction at work; and unspecified anxiety disorder. The preponderance of the evidence indicates that the psychiatric disorders were not manifest in service and are unrelated to service. Specifically, review of the Veteran’s service treatment records does not reflect a diagnosis as to a psychiatric disorder, or related complaints. Further, the May 2016 VA examination report mentions earliest treatment as being in 2012. Moreover, the evidence reflects that events causing the Veteran’s psychiatric symptomology occurred after service. Additionally, the preponderance of the evidence indicates that the Veteran’s major depression and unspecified anxiety disorder were not caused or aggravated by his service connected ankle disabilities. A July 2019 VA psychiatric examination report indicates that the Veteran’s psychiatric disorder was not due to, the result of, or aggravated by the Veteran’s ankle disability. The VA examiner stated that the two conditions were in different time frames, of different etiology, and of different anatomical systems, with no relationship between one and the other. The VA examiner stated that the Veteran’s depressive disorder has had the same clinical pattern or natural course as is present in those who do not have the service connected ankle disabilities and his mental disorder has had a mild course with a favorable medical response. It was noted that a May 2016 mental disorders disability benefits questionnaire had described the Veteran’s psychosocial and environmental problems as “laboral, financial stressors”; and that an April 2017 VA medical record noted depressive symptoms due to pain. However, the facts were clear. The mean stressor, and the reason for seeking psychiatric treatment, was labor stress. Moreover, depressive symptoms due to pain due to a service connected disability are not shown. Likewise, an August 2020 VA medical opinion opines that the Veteran’s unspecified anxiety disorder was not due to or aggravated by his service connected conditions. Instead, based on the current examination and endorsed statements, it was more likely that the anxiety disorder was related to job stress and medical conditions such as prostate cancer, complications of surgery, and pain, not specific to the service connected ankle conditions. The VA examiner noted that there was no evidence to suggest that the Veteran’s current mental disorder was due to or exacerbated by his service connected ankle disabilities. Also of record is July 2011 letter from Dr. Ortiz Valentin which indicates that the Veteran had chronic pain and consequently as depressed and that it was more probable than not that his nervous problems were service connected due to his musculoskeletal problems. However, this opinion is not probative because it does not specifically state what service connected musculoskeletal problems caused or aggravated his psychiatric disorders. Additionally, as to the Veteran’s submission in February 2021 concerning depression and pain, this submission provided medical information that was general in nature, and did not address the specifics of the Veteran’s case. Rather, the VA opinions, discussed above, considered the specific facts related to the Veteran’s case in conjunction with his medical history which far outweighed the generalities of the article submitted. Libertine, 9 Vet. App. at 523. Thus, based on the reasons and bases discussed, the preponderance of the evidence is against the claim, and the benefit of the doubt rule is inapplicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49, 54-56 (1990). Accordingly, service connection is not warranted for a psychiatric disorder. 9. Entitlement to service connection for a circulatory disorder Based on the evidence, the Board concludes that service connection is not warranted for the Veteran’s current circulatory disorder, which the evidence including an August 2010 VA medical record and September 2020 and January 2021 VA examination reports, indicates is bilateral lower extremity venous insufficiency (peripheral vascular disease). The preponderance of the evidence indicates that this was not manifest in service and is unrelated to service. Specifically, review of the Veteran’s service treatment records does not reflect a diagnosis as to a circulatory disorder, or related complaints. Instead, it such a disorder was first shown years post-service. Additionally, a VA examiner in June 2019 considered the matter of onset in or relationship to service, noting that the Veteran had had a right ankle injury in service. However, the VA examiner noted that the Veteran had never been diagnosed with phlebitis and opined that the Veteran’s current venous insufficiency was less likely than not incurred in or caused by service. The VA examiner noted that the Veteran’s service treatment records were silent for diagnosis, related complaints, and treatment for any circulatory disorder, and that none was shown within one year from the Veteran’s May 2003 service separation. Instead, the Veteran was first diagnosed with his venous insufficiency in 2010, seven years post-service. Due to all of these facts, the VA examiner opined that it was less likely than not incurred in or related to active duty. A VA examiner in January 2021 likewise opined that the Veteran’s venous insufficiency was less likely than not caused by or a result of service, as there was no evidence of it in the service treatment records. The preponderance of the evidence including a September 2020 VA medical opinion and the January 2021 VA examination report also indicated that the Veteran’s venous insufficiency was not caused or aggravated by his service connected right and left ankle disabilities. The VA examiner in January 2021 indicated that it was less likely than not secondary to the service connected bilateral ankle condition because there was no pathophysiological relationship between them based on a review of medical literature. The September 2020 VA examiner opined that it was not aggravated beyond its natural progression by the service connected ankle disabilities. The September 2020 VA examiner’s rationale was that there was no clinical and objective evidence to support that it was aggravated beyond its natural progression, that it was dated to years after service and had followed a natural progression. The September 2020 VA examiner further explained that by definition, the venous insufficiency and ankle disabilities were different disease entities with different pathophysiological processes unrelated to each other, and without biomechanical interaction. The September 2020 VA examiner also noted that the Veteran had only mild venous insufficiency in December 2014. The Veteran asserted in April 2010 that his claimed conditions were incurred in service. Also he asserted in February 2011 that he gained weight because of his ankles. However, his opinions as to these complex medical matters are not competent. Medical expertise is required. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Additionally, they are outweighed by evidence to the contrary. Thus, based on the reasons and bases discussed, the preponderance of the evidence is against the claim, and the benefit of the doubt rule is inapplicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. 49, 54-56 (1990). Accordingly, service connection is not warranted for a circulatory disorder. M. ESPINOZA Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher Lawson 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.