Citation Nr: 21014787 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 14-07 673 DATE: March 15, 2021 ORDER Entitlement to service connection for a right ankle disability (gout), to include as secondary to service connected Post Traumatic Stress Disorder (PTSD) is denied. Entitlement to service connection for a left ankle disability (gout), to include as secondary to service connected PTSD is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that his right ankle disability (gout) began during active service or is otherwise related to an in-service injury or disease. 2. The Veteran’s right ankle disability is not secondary to service-connected PTSD and is not otherwise related to an in-service injury or disease. 3. The Veteran’s right ankle disability was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established. 4. The preponderance of the evidence is against finding that his left ankle disability (gout) began during active service or is otherwise related to an in-service injury or disease. 5. The Veteran’s left ankle disability is not secondary to service-connected PTSD and is not otherwise related to an in-service injury or disease. 6. The Veteran’s right ankle disability was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established. CONCLUSIONS OF LAW 1. The criteria for service connection for a right ankle disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for a left ankle disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1989 to July 1994. These matters come to the Board of Veterans’ Appeals (Board) from a decision of the Agency of Original Jurisdiction (AOJ). In May 2011, the AOJ issued a rating decision that denied the Veteran’s claims for service connection for a left and right ankle disability, to include gout as secondary to his service-connected PTSD. The Veteran timely disagreed in a May 2012 Notice of Disagreement (NOD) and perfected his appeal in a March 2014 VA Form 9. The Board notes the Veteran’s entitlement claims have been remanded several times before, most recently in September 2019, for another VA disability examination. In December 2019, a new disability examination was conducted. Then, in July 2020, the AOJ readjudicated the Veteran’s entitlement claims and continued its denial of service connection for a left and right ankle disability. In September 2020, the Veteran’s case was returned to the Board. 1. Entitlement to service connection for a right ankle disability (gout), to include as secondary to service connected PTSD. 2. Entitlement to service connection for a left ankle disability (gout) to include as secondary to service connected PTSD. The Veteran contends his left and right ankle disabilities are related to his service. See May 2012 NOD at 1. The Veteran also contends his ankle disabilities should be service connected based on continuity of symptomatology. See March 2014 VA Form 9 at 2. He claims he injured both ankles during service and observed problems with them following service, when he was diagnosed with gout. See July 2019 Statement. In the alternative, the Veteran contends his left and right ankle disabilities were proximately caused by or aggravated by his service-connected PTSD. The questions for the Board are whether there is sufficient evidence to find his left and right ankle disabilities are related to his service or secondary to any other service-connected disability. For the reasons discussed below, the Board concludes that the evidence does not support a grant of service connection on a direct or secondary basis or based on chronicity or continuity of symptomatology. Entitlement to service connection requires evidence of three elements: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the current disability and the disease or injury incurred or aggravated during active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (2007). Another way a Veteran can establish service connection is by satisfying the test for disability compensation for chronic diseases set forth in 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331, 1334 (2013). To satisfy that test the Veteran must (1) have a chronic disease listed under 3.309(a) and (2) that disease must have been “shown in service.” Id. at 1335. As to (1), gout is a form of arthritis, which is listed as a “chronic” disease under 38 C.F.R. § 3.309(a). As to (2), 38 C.F.R. § 3.303(b) equates “shown in service” with a reliable diagnosis of the chronic disease while in service. Walker, 708 F.3d at 1335. If the Veteran satisfies the test for disability compensation for chronic diseases in 38 C.F.R. § 3.303(b), the Veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability is sought. Id. Another method under 38 C.F.R. § 3.303(b) is to show continuity of symptomatology. Continuity of symptomatology may be demonstrated if a claimant can show (1) a condition was “noted” during service; (2) postservice evidence of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the postservice symptomatology. Savage v. Gober, 10 Vet. App. 488, 495 (1997). Section 3.303(b) does not require medical evidence of an etiological link between service and a current disability. Walker, 708 F.3d at 1338-40. If the Veteran satisfies the test for disability compensation for chronic diseases in 38 C.F.R. § 3.303(b), the Veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability is sought. Id. at 1336. Also, a Veteran may establish service connection on a secondary basis for a disability which is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a). Or for any increase in the severity of a nonservice-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 progression of the nonservice-connected disease. 38 C.F.R. § 3.310(b) Entitlement to service connection under 38 C.F.R. § 3.310(a) or (b) requires evidence of three elements: (1) evidence of a current disability that is not service-connected; (2) evidence of a service-connected disability; and, (3) evidence of nexus establishing a connection between the service-connected disability and the current disability. 38 C.F.R. § 3.310. In order to prevail on a claim for benefits under any of the theories listed above, the Veteran need only demonstrate there is an approximate balance of positive and negative evidence. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). This is because the Veteran is entitled to the “benefit of the doubt” when the evidence is approximately balanced. Id. at 53. Beginning with the Veteran’s service, at entrance the Veteran was evaluated for medical conditions; no ankle condition was noted. See October 22, 2018, Report of Medical Examination. Part of that exam included completing a questionnaire that afforded him the opportunity to report any problems for the doctor to consider; he denied any significant medical history and noted he is in “excellent health.” See October 22, 2018, Report of Medical History. The Veteran’s service treatment records (STR) show that, while in basic training, he injured his right ankle. In August 1989, during basic training, the Veteran visited sick-call for complaints related to his right ankle. The doctor who examined him noted no trauma in the last 72 hours, no redness, and mild swelling. The Veteran was referred to podiatry. The next day, the Veteran visited a podiatry clinic: The podiatrist noted the Veteran internally twisted his right ankle. After the podiatrist conducted his examination, he diagnosed “lateral inversion [right] ankle sprain.” The Veteran was placed on a limited activity profile as part of his recovery plan. See August 25 and 26, 1989, STRs. In 1992, about three years into his service, the Veteran visited sick-call for a left ankle injury. He reported that, earlier in the day, he twisted his left ankle during physical training. Since he did not find the pain significant, he continued with his day. Around lunchtime, he went to the gym and twisted his ankle again. See January 15, 1992, STR. During his evaluation, he reported he has no history of ankle trouble; foot pain and deformity was noted. The Veteran was diagnosed with a (left) ankle sprain. Id. In May 1994, the Veteran underwent a separation examination. Part of that exam included completing a questionnaire that afforded him the opportunity to report any problems for the doctor to consider; the Veteran reported an ankle injury during basic training, among other problems. The doctor did not add any additional comments related to that report. See May 2, 1994, Report of Medical History at 2. VA Medical Center records (VAMC) following service note complaints of pain at both ankles. In October 2010, he complained of pain and swelling at both ankles. The doctor who examined him noted “Impression: . . .[bilateral] ankle pain-injured in service and treated in service.” She did not provide a rationale supporting her impression. See October 28, 2010 VAMC record by C.S.W. In October 2010, the VA received statements from the Veteran and his wife. In the Veteran’s statement, he describes events during his service to support his entitlement claim for his (now) service-connected PTSD. Towards the end of the statement, he adds that he observes joint pain. See March 2010 Statement at 2. His wife provided her observations of behavior changes associated with the Veteran’s (now) service-connected PTSD. Within that statement, she includes one sentence that indicates the Veteran complained of ankle pains sometime after 1992. See March 2010, Statement at 1. A November 2010 VAMC record indicates the Veteran may have gout at his right ankle. The doctor noted the Veteran’s uric acid level is high. She also notes the Veteran reported his uric acid level was high in the past. See November 12, 2010, Record by C.S.W. In June 2011, the Veteran underwent a VA disability examination for his ankle disabilities. The Veteran reported he observed severe pain (described as a 7 out of 10). He also reported flare-ups (described as 10 out of 10). And he has difficulty walking. See June 2011 VA disability examination at 2. The examiner noted the diagnosis of gout. Id. The examiner acknowledged the Veteran’s right ankle injury in 1989 and left ankle injury in 1992. The examiner also noted the Veteran was involved in a car accident and complained of knee and ankle pains. Then, without any explanation, he concluded the Veteran’s diagnosed gout is not related to his service. Id. After the Board issued its January 2018 remand, the Veteran underwent two VA disability examinations later that year. During the Veteran’s October 2018 disability examination for arthritis, the Veteran reported he started observing chronic and recurrent pain in both ankles in 1989. And he was diagnosed with gout in 2010. See October 2018 VA DBQ Nondegenerative Arthritis at 3.The Veteran also reported incapacitating episodes. He reported incapacitating episodes occur about four or mor times a year, they can last for days, and were described as severe pain with decreased range of motion and swelling. Id. at 4. The examiner noted the diagnosis of gout. Id. at 2. She also noted the Veteran does not have pain attributable to this arthritic condition or limited motion at those areas due to the arthritic condition. Id. During the Veteran’s October 2018 VA disability examination for ankle conditions, the examiner noted the Veteran does not have degenerative or traumatic arthritis. See October 2018 VA DBQ Ankle Condition at 9, 18. The Veteran did not describe his ankle disabilities any different than he did during the previous exam. The examiner acknowledged and noted the Veteran’s report of pain; however, she did not attribute the pain to any form of arthritis. Then the examiner prepared a medical opinion wherein she concludes the Veteran’s gout at both ankles is not related to his service. The examiner explained that gout is caused by elevated levels of uric acid and there is no mechanism by which isolated ankle strains might result in the physiological changes that cause elevated uric acid levels. The examiner pointed to evidence in the record as support for her conclusion that the injuries in this case do not lead to the development of gout. Specifically, the lack of complaints of ankle abnormalities at separation, clinical evaluation at separation that did not note any ankle abnormalities, and actual diagnosis of gout several years after service. See October 2018 DBQ Medical Opinion at 2. The examiner indicated that she considered whether there were indications of gout during service, regardless of the Veteran’s ankle injuries. She explained that the Veteran’s service medical records did not indicate the Veteran had gout while in service. Id. So, she concluded that Veteran’s diagnosed gout was not related to his service. In July 2019, the VA received statements from the Veteran and his wife. The Veteran indicates his service records show he had two ankle injuries and sought medical treatment for them. See July 2019 Statement at 1. And, even though his service records show he did not go to sick-call for treatment, he did observe problems with both ankles. Id. And, following service, he observed pain, discomfort, and limited motion in both ankles. Id. at 2. He adds that he sought medical attention at times and, other times, he would work through the injury until he could no longer walk. He added that the symptoms observed following service interfered with some activities. Id. at 2. He states that, due to pain, he could not run and play with them. The pain interferes with his ability to play with his grandchildren. He emphasized his ankle problems began before his diagnosis of gout and believes it is related to his in-service ankle injuries. His wife states she knew the Veteran before his ankle injuries occurred and has observed him since those injuries. See July 2019 Statement from Wife at 1. She adds that she took care of him after his second injury (in 1992). Id. at 2. She states the Veteran did not complain of ankle pain before his ankle injuries but has complained of pain since them; she stated he suffered pain, limited motion, and discomfort. Id. She adds that his suffering and pain is pretty consistent. She observed the Veteran’s ankle disabilities interfered with his ability to be active with his children. Now, it interferes with his ability to be active with his grandchildren. Id. She adds that, even though the Veteran did not seek medical attention, he did have pain. In August 2019, the Veteran, by way of his representative, referred to three online articles to support his entitlement claims. The first was a general informational article on gout which allegedly states that stress triggers a gout attack. In addition to a brief description of gout, it lists seven risk factors if you already have his levels of uric acid in your body: they are diet; obesity; medical conditions; certain medications; family history of gout; age and sex; and recent surgery or trauma. It does not explicitly state that stress or injuries lead to the development of gout. Gout, mayoclinic.org, https://www.mayoclinic.org/diseases-conditions/gout/symptoms-causes/syc-20372897 (last visited March 2, 2021). The second article, titled “Gout Triggers” states medical stress like hospital visits, surgery, pneumonia and other medical conditions can cause gout flares. The article begins with “[w]hen suffering from gout you need to take note of the list of potential gout triggers” and later asserts that uric aric tends to form more readily around injured joints. So, injuries, like twisting your ankle or stubbing your toe. It does not explicitly state that injuries lead to the development of gout. Gout Triggers, goutandyou.com, https://goutandyou.com/gout-triggers/ (last visited March 2, 2021). The third article, “Stress and Gout: What is Overlooked,” was cited in order to support a link between stress and gout. The article discusses the effects stress has on the body, which in turn can affect someone with gout. The article asserts that stress causes affects the digestive system and that system affects the occurrence of gout attacks. And in that discussion, it associates PTSD to gout, through an intermediate condition, sleep apnea. The article does not go so far as to assert that PTSD directly causes gout. Nor does it assert that any mental disorder causes gout. It discusses the effects of stress in order to manage gout attacks. It does not explicitly state that stress or injuries lead to the development of gout. Stress and Gout: What is Overlooked, conquergout.com, https://conquergout.com/stress-and-gout-what-is-overlooked/ (last visited March 2, 2021). In December 2019, the Veteran underwent two VA disability examinations for his ankle conditions. During the first exam, the Veteran reported he started observing chronic and recurrent pain in both ankles in 1989. And he was diagnosed with gout in 2010. He reports the condition continues to get worse and, at times, he uses crutches or a wheelchair to get around. See December 2019 VA DBQ Nondegenerative Arthritis at 3, 6. He also reported flare-ups and incapacitating episodes. He reported incapacitating episodes occur about four or mor times a year, they can last for days, and were described as severe pain with immobility. Id. at 4. The examiner noted the diagnosis of gout. Id. at 2. He also noted the Veteran has pain at his knee, ankle, and foot that is attributable to this arthritic condition. Id. at 3. And he has limited motion at those areas due to the arthritic condition. Id. During the second examination, the examiner noted the Veteran does not have degenerative or traumatic arthritis. See December 2019 VA DBQ Ankle Conditions at 2, 14. The Veteran did not describe his ankle disabilities any different than he did during the previous examination. Then the examiner prepared a medical opinion wherein he concludes the Veteran’s gout at both ankles is not related to his service. See December 2019 DBQ Medical Opinion at 1. The examiner explained that gout is caused by elevated levels of uric acid and there is no mechanism by which isolated ankle strains might result in the physiological changes that cause that. Id. at 1. Nor is there medical evidence that supports a relationship between a twisted ankle and gout. Id. at 3. For the same reason, the examiner opined that the Veteran’s diagnosed gout was not caused by or aggravated by his service-connected PTSD. Id. at 4, 5. The examiner explained that there is no there is no mechanism by which PTSD might result in the physiological changes that cause that gout. Id. at 5. And there is no evidence to support PTSD and gout are related conditions. Id. So, the gout was not proximately caused by the Veteran’s PTSD. Id. at 4. And PTSD cannot aggravate gout. Id. at 4.   A. Entitlement to service connection on a direct basis. Turning to the Veteran’s claim for disability compensation, the first question is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.303. The first issue to answering the question is whether the Veteran has a current disability. The record reflects the Veteran has been diagnosed with gout at both ankles, most recently in the December 2019 VA disability examination. Thus, the record reflects a medically diagnosed left and right ankle disability. The next issue is whether the Veteran has an in-service incurrence or aggravation of a disease or injury. The Board recognizes the Veteran has provided several statements asserting he injured his ankles during service and provided reasons for not going to sick-call for those injuries; but because his service treatment records show those injuries occurred, there is no doubt he injured his left and right ankles during service. As a result, the evidence weighs in favor of finding the he had two in-service ankle injuries: a right ankle injury in 1989, and a left ankle injury in 1992. The next issue is whether there is a nexus between the Veteran’s ankle injuries and service. The Board recognizes the Veteran injured his ankles while in service and his diagnosed gout affects them; however, in this case, his lay observations and statements are not competent to support a nexus. Here, he has not alleged to possess the qualifications to opine on an etiological link between a sprain or twisted ankle and gout; so, his statements are not competent towards establishing a causal connection between them. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). The three online articles cited by the Veteran were considered; however, they were assigned little to no probative value. The article on the Mayo Clinic’s website, titled “Gout” did not discuss whether an injury, like a twisted ankle, causes gout. Nor did the article titled, “Stress and Gout: What is Overlooked.” Thus, they were not relevant to the issue of a nexus and, therefore, were not considered. The article, “Gout Triggers,” does address whether there is a relationship between an injury, like a twisted ankle, but not in the context of an etiological link. The article begins with “[w]hen suffering from gout,” which presumes the person already has that condition. When the article is read as a whole, it does not assert a traumatic injury causes gout; instead, it asserts that a person suffering from gout can experience flares at an area he or she suffered a traumatic injury. Because an injury’s effect on an individual who already has gout is not relevant to the issue of a nexus, it was assigned little to no weight. The Board recognizes several VA disability examinations were conducted during the period on appeal and only two of them addressed the issue of a nexus between the Veteran’s ankle disabilities and service; they were the June 2010 and October 2018 examinations. Beginning with the June 2010 examination, the Board agrees with the Veteran that the examiner did not consider or discuss the Veteran’s lay statements. See August 2017 Appellate Brief at 2. So, it is not apparent to the Board whether the examiner was cognizant of all the relevant details of the Veteran’s past medical history. Nievez, 22 Vet. App. at 301. As a result, it was not considered. The October 2018 VA disability examination was adequate to evaluate the Veteran’s disability claims. The examiner interviewed the Veteran, acknowledged and considered his statements, and reviewed his file. Even though he did not note every lay statement made by the Veteran, she appeared to be fully cognizant of the relevant details of the Veteran’s past medical history to decide on the issue of a nexus. Id. Also, the examiner provided a reasoned explanation for his conclusion. The examiner acknowledged the Veteran had two in-service ankles injuries but indicated they could not be related to his later diagnosed gout. See October 2018 VA DBQ Medical Opinion at 2. She noted that there is no process by which isolated injuries can lead to the physiological changes that cause gout. Id. The examiner also considered whether gout was present during service, but noted there was no evidence to conclude it was. Id. The examiner’s opinion was sufficient for the Board to evaluate whether the data she relied on connects to her conclusion. Nievez, 22 Vet. App. at 301. So, the Board assigned the opinion significant weight. The Board recognizes the Veteran and his wife submitted additional lay statements after the October 2018 VA disability examination was conducted; but it is apparent to the Board that consideration of those statements would not have altered the opinion. Those statements included additional reports of pain and explained why there are few medical records showing treatment or complaints of pain. Considering that the examiner made clear there was no process by which the Veteran’s ankle injuries could have caused him to develop gout, it is unlikely that more reports of ankle pain would have impacted the examiner’s conclusion. The Board also recognizes the October 2010 VAMC record that noted “Impression: . . .[bilateral] ankle pain-injured in service and treated in service.” See October 28, 2010 VAMC record by C.S.W. But there was no rationale supporting her conclusion; so, it is afforded little probative weight. In this case, the Board finds the evidence was not approximately balanced on the issue of a nexus. The evidence weighing in favor of a nexus was an online article that had little relevance to a nexus. And the limited probative value that article was outweighed by the more probative October 2018 VA disability examination. So, doubt could not be resolved in the Veteran’s favor. Gilbert, 1 Vet. App. at 54. As a result, the Board finds there is no nexus between the Veteran’s ankle disabilities and his service. Since the Veteran has not established a nexus between his diagnosed gout and the two ankle injuries during service, he has not established entitlement to service connection under 38 C.F.R. § 3.303. B. Entitlement to service connection based on a theory of continuity of symptomatology. The next question is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.303(b). The first issue is whether the Veteran has a chronic disability listed under 38 C.F.R. § 3.309(a).  Gout is a form of arthritis (also called gouty arthritis), which is a disease listed under § 3.309(a); therefore, the Veteran has a chronic disease eligible for service connection under 3.303(b). The next issue is whether the Veteran’s symptoms of the Veteran’s ankle disabilities were noted during service. 38 C.F.R. § 3.303(b). The lay evidence of record supports a finding that the Veteran observed pain during service. The Veteran is competent to report pain. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Veteran’s lay assertions of left and right ankle pains during service have been consistent throughout the appeal period. Which are supported by the statements from his wife. So, the Board finds the Veteran’s statements credible towards observations of pain during service. Although the Veteran is competent to report pain, he has not shown it is a symptom of gouty arthritis. Arthritis is defined as “inflammation of a joint,” with over seven different forms of arthritis listed with it, to include viral, degenerative, and gouty. DORLAND’S ILLUSTRATED MEDICAL DICTIONARY (DORLANDS) 154 (33rd ed. 2020). So, it is a medically complex question which the Veteran has not alleged he is qualified to answer. Jandreau, 492 F.3d at 1377. Nor is the Board. Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Since the Veteran’s diagnosed gout is not a condition a lay person is competent to identify, medical evidence is required to satisfy the noting requirement. Savage, 10 Vet. App. at 497. The October 2018 VA disability examination is medical evidence that weighs against finding that his observed pain is a symptom of gouty arthritis. The examiner recognized the Veteran’s reports of ankle pains during service when concluding the Veteran’s ankle injuries could not cause gout. See October 2018 VA DBQ Ankle Conditions at 3; October 2018 VA DBQ Medical Opinion at 2. If the examiner viewed those reports of pain as symptoms of gout, she would not have concluded there is no nexus; so, her opinion is probative evidence against finding his observed pain is a symptom of gouty arthritis. It is apparent to the Board that examiner thoroughly evaluated the association between the Veteran’s pain at his ankles and his diagnosed gout. The examiner conducted two evaluations of the Veteran’s ankles: in the first, she evaluated the Veteran’s ankles to find any associated ankle condition. In the second exam, she focused on arthritis and its relation to his ankle disabilities. Thus, it is clear she devoted time to evaluating the Veteran’s reports of pain to gout and any other condition. As a result, the opinion was assigned significant weight against a noting of gouty arthritis during service. In this case, the evidence is not approximately balanced on the issue. Even though the Veteran has provided competent evidence of pain, neither he nor the Board can decide whether it is a symptom of gouty arthritis. But the examiner who provided the October 2018 VA medical opinion can: She determined the Veteran’s reports of pain are not indicative of gouty arthritis. Thus, doubt could not be resolved in the Veteran’s favor. Gilbert, 1 Vet. App. at 54. Even though the Veteran has not shown his diagnosed gout was noted during service, the Board considered whether the Veteran has provided evidence that relates gout at both ankles to continuous symptoms of pain since service. The Board finds that the evidence does not establish a link between them. The Veteran’s lay observations of pain following service weigh in favor of finding continuous symptoms. He asserts that he has observed pain since service, and it progressed since leaving service. See May 2012 NOD; July 2019 Statement at 2. The Veteran’s statements have been consistent throughout the appeal period. And his reports are supported by statements from his wife. His wife has personal knowledge of what the Veteran has she has heard the Veteran tell her. So, she is competent to report it. Layno, 6 Vet. App. at 469. She indicated she has observed the Veteran since his injury and heard him complain of pain. It is probable that a spouse would recall the other spouse’s reports of pain. So, the Board finds her statements credible. It also adds credibility to the Veteran’s statements. Considering the Veteran has not shown his observed pain since service is a symptom of gouty arthritis, his statements were assigned some, but not significant weight. The October 2018 VA disability examination for arthritis weighs against finding continuous symptoms. The examiner noted that Veteran’s pain is not associated with gouty arthritis. See October 2018 VA DBQ Nondegenerative Arthritis at 4. The finding in that exam casts doubt on the likelihood that the Veteran’s continuous symptoms of pain are related to his gouty arthritis. Since the examiner is qualified to evaluate whether the Veteran’s pain is due to arthritis or another condition, that finding was assigned significant weight. Even though the examiner noted ankle pain during another examination of the Veteran, the Board sees no inconsistency. See October 2018 VA DBQ Ankle Conditions at 3-5. Pain is more or less a localized sensation of discomfort or distress, resulting from the stimulation of specialized nerve endings. DORLANDS at 1343. That definition is broad, and, at least when it comes to the ankle, not restricted to one or more condition. So, even though the examiner noted observations of pain, her conclusion that it was not related to arthritis implies that she determined it is associated with something else. Although she does not clearly state what the Veteran’s observations of pain over time may be due to, that does not diminish the probative value of her conclusion it is not due to gouty arthritis. The December 2019 VA DBQ for arthritis does find that the Veteran has pain due to gouty arthritis; but it does not support a finding that the Veteran’s has observed continuous symptoms of arthritic pain since service. See December 2019 VA DBQ Nondegenerative Arthritis at 3. In the medical opinion that followed, the examiner acknowledged the Veteran had gout since 2010, but concluded that the Veteran’s ankle injuries could not cause gout. Based on that opinion, it is apparent to the Board that the examiner did not view all of the Veteran’s observations of pain since service to be symptomatic of the same condition; if the examiner had, it is not likely he would have concluded there is no nexus. So, the opinion was not considered evidence weighing in favor of continuous symptoms. In this case, Board finds the evidence is not approximately balanced on the issue of continuous symptoms. Although the Veteran provided probative evidence of pain at his ankles, he is not qualified to identify those pains as symptoms of gouty arthritis. But the examiners who conducted the more probative October 2018 and December 2019 examinations can: The one who evaluated the Veteran in 2018 noted the Veteran did not have arthritic pain; the one that evaluated him in 2019 found there was arthritic pain. Pain observed during a later examination does not invalidate an earlier exams notation of no pain. Read together, they support a finding that the Veteran did not have continuous symptoms since service. So, doubt could not be resolved in the Veteran’s. Gilbert, 1 Vet. App. at 54. Since the Veteran has not shown a notation of gouty arthritis in service nor continuous symptoms following service, the Veteran has not established entitlement to service connection based on continuity of symptomatology. C. Entitlement to presumptive service connection. The next question is whether the Veteran’s diagnosed gout was shown to a degree of 10 percent or more in service or within one year after service. 38 C.F.R. § 3.307. As explained above, the Veteran’s lay observations are not competent to identify its existence. Savage, 10 Vet. App. at 495-96. Nor does the record provide sufficient evidence to support finding the disease identity at that time. Walker, 708 F. 3d. at 1335-36. So, the Board finds the evidence does not establish entitlement to service connection for arthritis on a presumptive basis. D. Entitlement to service connection for a left and right ankle disability (gout) on a secondary basis. The next question is whether the Veteran has established entitlement to service connection under 38 C.F.R. § 3.310(a) or (b). Since the Veteran has already satisfied the requirement of a current non-service connected disability, the next issue is whether the Veteran has at least one service-connected disability. The record reflects he is service-connected for PTSD, gastroesophageal reflux (GERD), a scar, and residuals of that scar. Although that amounts to four disabilities, he only contends PTSD caused or aggravated his ankle disabilities. The Board notes that the Veteran has not alleged nor does the record raise the inference of a claim for service connection under 38 C.F.R. § 3.310 based on any other service-connected disability. The next issue is whether the Veteran’s ankle disabilities were proximately caused by his service-connected PTSD. Two online articles cited by the Veteran discuss whether stress or PTSD are related to gout. Stress, inasmuch as it relates to PTSD, is defined as “a state of physiological or psychological strain caused by adverse stimuli, physical, mental, or emotional... that tend to disturb the functioning of an organism.” Stress, DORLANDS at 1754. Although the Veteran asserts that the article, “Gout,” discusses the effects of that form of stress on gout—it does not. See August 2019 Appellate Brief at 3. And even if it did, it would not have been of much probative value because the article was not relevant to the issue of causation. Its discussion of risk factors begins with “if you have high levels of uric acid in your body,” which makes clear it is addressed to individuals who already have high uric acid levels in his or her body (gout); not whether stress causes high uric acid levels in the body. So, the article was not considered. It is less clear whether the article, “Stress and Gout: What is Overlooked,” discusses people who already have gout; but, even if it did, the article does not discuss whether there is a direct, causal link, between PTSD and gout. The article suggests an indirect link, through sleep apnea, which amounts to speculative evidence of an association between PTSD and gout. As a result, it had little probative value and was assigned little to no weight. The December 2019 VA disability examination is medical evidence that weighed against a finding of causation. The examiner conducted a personal examination, reviewed the Veteran’s claims file, as well as acknowledged and considered the Veteran’s two in-service ankle injuries. So, the examiner appeared fully cognizant of the relevant details of the Veteran’s past medical history. Nievez-Rodriguez, 22 Vet. App. at 301. Also, the examiner provided a reasoned explanation for his conclusion that that the Veteran’s service-connected PTSD did not cause his gout. The examiner explained that the two conditions are not related. And he emphasized that there is no medical evidence that supports a causal link between the two conditions. The examiner’s rationale is sufficient for the Board to evaluate whether the data he relied on connects to his conclusion. Id. As a result, the Board assigned the opinion significant weight against a finding of causation. As to the issue of causation, the Board finds the evidence is not evenly balanced. Although the online article “Stress and Gout: What is Overlooked” suggests there is a link, it is an indirect one that was of little to no probative value towards deciding the issue. And it was outweighed by the more probative December 2019 VA medical opinion that concluded the Veteran’s ankle disabilities were not caused by his service-connected PTSD. So, doubt cannot be resolved in his favor. Gilbert, 1 Vet. App. at 54. As a result, he is not entitled to service connection under 38 C.F.R. § 3.310(a). The next issue is whether the Veteran’s ankle disabilities were aggravated by his service-connected PTSD. The only medical evidence that address the issue of aggravation is the December 2019 VA medical opinion, which concluded the Veteran’s service-connected PTSD did not aggravate his ankle disabilities. The examiner explained that there is no physical mechanism by which the Veteran’s particular ankle injuries could lead to gout. Nor is there medical evidence to support it does. See December 2019 VA DBQ Medical Opinion at 4, 5. The examiner’s explanation connects both the data he relied on to his conclusion. Nievez, 22 Vet. App. at 301. And the Board assigned it significant probative weight against a finding of aggravation. As to the issue of aggravation, the Board finds the evidence is not approximately balanced. The only medical evidence that addresses this issue weighed against the Veteran’s claim. So, doubt could not be resolved in the Veteran’s favor. Gilbert, 1 Vet. App. at 54. As a result, he is not entitled to service connection under 38 C.F.R. § 3.310(b). In sum, the Veteran has not established entitlement to service connection for his diagnosed gout at his left and right ankles under 38 C.F.R. §§ 3.303, 3.307, nor 3.310. Also, the Veteran has not raised any other issues nor have any other issues been reasonably raised by the record. Robinson v. Peake, 21 Vet. App. 545, 552-54 (2008) (holding the Board is not required to address issues unless specifically raised by the claimant or reasonably raised by the record). The Board thanks the   Veteran for his service to our country and regrets a more favorable decision could not be reached in his case. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dean, Michael S. 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.