Citation Nr: 21028697 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 13-34 140A DATE: May 11, 2021 ORDER Entitlement to service connection for chest bursitis is denied. Entitlement to service connection for left ankle disability is denied. Entitlement to service connection for right ankle disability is denied. Entitlement to service connection for hemorrhoids is denied. Entitlement to service connection for gastritis is denied. Entitlement to service connection for left hip bursitis is denied. Entitlement to service connection for foot fungus is denied. FINDINGS OF FACT 1. The weight of evidence is against a finding that the Veteran has had a chest bursitis disability at any time during the period on appeal. 2. The weight of evidence is against a finding that the Veteran has had a left ankle disability at any time during the period on appeal. 3. The weight of evidence is against a finding that the Veteran has had a right ankle disability at any time during the period on appeal. 4. The weight of evidence is against a finding that the Veteran has had a hemorrhoids disability at any time during the period on appeal. 5. The weight of evidence is against a finding that the Veteran has had a gastritis disability at any time during the period on appeal. 6. Degenerative joint disease of the left hip was not manifest during active service, or until many years after service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 7. Onychomycosis of the feet was not manifest during active service, or until many years after service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for a chest bursitis disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). 2. The criteria for service connection for a left ankle disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). 3. The criteria for service connection for a right ankle disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). 4. The criteria for service connection for a hemorrhoids disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). 5. The criteria for service connection for a gastritis disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). 6. The criteria for service connection for a left hip bursitis disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2020). 7. The criteria for service connection for a foot fungus disability have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1974 to June 1977, and from June 1977 to June 1980, with a period in the Army National Guard from April 1982 to February 2001 which included periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Baltimore, Maryland. A Board hearing for these issues was held in January 2017 before the undersigned Veterans Law Judge (VLJ) sitting in Washington, D.C. A copy of the transcript of that hearing is of record. This appeal was originally certified to the Board with three additional issues: entitlement to service connection for right shoulder, left shoulder, and right hip disabilities. However, in a March 2021 rating decision, the RO granted entitlement to service connection for a right shoulder, left shoulder, and right hip. As such, the issues are no longer in appellate status before the Board. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). The Board notes the presence of a separate adjudication with different issues on appeal for this Veteran by a different VLJ who signed a decision dated December 29, 2020. The issues in that decision do not overlap or relate to the issues in this appeal. The Board remanded the issues on appeal for additional development in November 2017 and January 2021. The directives having been substantially complied with, the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2020). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert. denied, U.S.C. Oct. 3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). Service Connection - General Legal Criteria for Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement." Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be established for a current disability on the basis of a presumption that certain chronic diseases, to include arthritis, manifesting themselves to a certain degree within a certain time after service must have had their onset in service. 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309(a). For arthritis, the disease must have manifested to a degree of 10 percent or more within one year of service. 38 C.F.R. § 3.307(a)(3). Service connection can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. For chronic diseases shown as such in service or within the applicable presumptive period, subsequent manifestations of the same chronic disease at any later date are service-connected unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). For a chronic disease to be considered to have been "shown in service," there must be a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings. Id. When the condition noted in service or within the presumptive period is not a chronic disease, a showing of continuity of symptomatology after discharge is required. Id. VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability benefits. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When analyzing lay evidence, the Board should assess the evidence and determine whether the disability claimed is of the type for which lay evidence is competent. See Davidson, 581 F.3d at 1313; Kahana v. Shinseki, 24 Vet. App. 428 (2011). Proof of a current disability is a threshold to establishing service-connection for any claimed disability. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To be a present as a current disability, there must be evidence of the condition at some time during the appeals period. Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a) (2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2020). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. Evidence and Analysis The Veteran has testified during his January 2017 hearing before the undersigned Veterans Law Judge that his bilateral ankle, chest and left hip bursitis, gastritis, foot fungus, and hemorrhoids disabilities originated in service and have continued into the present day. 1. Entitlement to service connection for chest bursitis The Veteran asserts that his bursitis of his bilateral hips, bilateral shoulders, and chest, began in service. The Veteran testified that he had shoulder and chest pain in service, and that his bursitis has moved and spread elsewhere. See January 2017 hearing transcript. A November 1976 service treatment record indicates shoulder pain, and a service treatment record from his National Guard service dated May 1998 indicates bursitis of the Veteran's right hip and upper extremities. Upon examination in May 1998, the Veteran reported joint pains. Private treatment records from 1998 also indicate a diagnosis of bursitis of the right hip and right shoulder, with reports of hip pain. Private treatment records from October 2005 note a diagnosis of bursitis in the hip area, but not the chest. VA provided a medical examination for the claimed chest bursitis in March 2019. The examiner diagnosed a resolved issue of chest pain based on the Veteran's reported history of being pushed in the chest during basic training in 1974, claiming he developed chest pain and swelling that averaged twice a year. The Veteran was asymptomatic and had never been diagnosed with any cardiac or lung disease or pathology. Physical examination of the chest wall was normal; it was symmetrical and equally expandable in the respiratory cycle. There was no visible chest wall anatomic abnormality and there was no chest wall abnormality or chest wall tenderness. The lungs were clear as to auscultation and resonant to percussion bilaterally. A heart exam indicated regular rate and rhythm, with no murmurs, rub, or gallop. The examiner noted there was no pathology found for a chest bursitis complaint and that there was no current disability. The Board finds the March 2019 examination to be highly probative as it is sound and thorough, and had sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting medical literature and clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, there is no diagnosis of a current disability of a chest bursitis condition by any VA medical examiner. Thus, the Veteran's claim does not meet the first prong of service connection, the requirement of a current disability. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. The Board notes that the existence of a current disability at any time during the current appeal period is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that, at some time during the current appeal period, the Veteran has the disability for which benefits are being claimed. Here, however, as noted above, the competent and credible evidence of record does not establish that, at any time during the current appeal period, the Veteran has had a diagnosis of a chest bursitis disability. In this regard, the Board notes that Congress has specifically limited service connection to instances where there is current disability (during the current appeal period) that has resulted from disease or injury. 38 U.S.C. § 1110. In the absence of a current disability during the current appeal period, the analysis ends, and the claim for service connection for a chest bursitis disability cannot be granted. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). Upon review of the evidence of record, the Board finds that the weight of the competent and probative evidence does not demonstrate that entitlement to service connection is warranted for the Veteran's claimed chest bursitis. Here, no examiner or medical professional has made a diagnosis of a current disability related to the Veteran's claimed chest bursitis. The examination at active service exit in June 1980 indicate no current disability of either a chest bursitis or related disability. The Board notes the statements from the Veteran regarding his chest bursitis. Generally, lay evidence is probative with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence on its own can be sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. However, a layperson cannot provide evidence as to more complex medical questions and, specifically, cannot provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). To the extent that the Veteran can observe symptoms in his body, to include chest bursitis, he is competent to comment on and endorse these symptoms. However, the determination of the etiology of a chest bursitis condition is a complex medical determination beyond his competence. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, the Veteran's statements over time, across three different appeal streams, to include testimony before two different VLJs, indicate at times facial plausibility, internal consistency, consistency with other evidence, and self-interest or bias, which reduces the overall credibility of the Veteran's statements about his disabilities. Accordingly, his assertions to that effect are of no probative value. Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, there is no diagnosis of a current disability of chest bursitis by any VA medical examiner. Thus, the Veteran's claim fails the first prong of service connection, the requirement of a current disability. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Because the Veteran has no in-service or related disease or injury that occurred in service or within one year after leaving active service that is not already accounted for in his other service-connected disabilities, the Veteran fails the second prong of the test for entitlement to direct service connection for his claim of chest bursitis. See id. The Board has considered the recent holding in Saunders v. Wilkie in which service connection was deemed possible in the absence of a diagnosis when such factors as pain are shown to limit functional ability. Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018) ("pain alone can serve as a functional impairment and therefore qualify as a disability"). That Federal Circuit decision qualified that holding, however: "[w]e do not hold that a veteran could demonstrate service connection simply by asserting subjective pain.... To establish the presence of a disability, the veteran will need to show that [his] pain reaches the level of functional impairment of earning capacity." Id. at 1365. In this case, however, the VA examination conducted during the pendency of this appeal in March 2019 did not show any symptoms of a chest bursitis disability, to include symptoms of pain for the claim. The Veteran has received an examination for his claimed chest bursitis, but there has been no observation of symptoms for a chest bursitis disability. The examiner specifically wrote that no pain was noted on the examination for the chest area. The examiner determined that any pain, weakness, fatigability, or incoordination did not limit any functional ability. The examiner determined there was insufficient current objective pathology for the claimed chest bursitis, and thus the Veteran does not have a current diagnosis associated with any condition of his chest bursitis. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed chest bursitis condition was not incurred in service. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a chest bursitis condition, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for left ankle disability 3. Entitlement to service connection for right ankle disability At the January 2017 hearing, the Veteran asserted that his ankle disabilities are the result of his jogging and running in service. The Veteran testified that his right ankle gives away while he is walking and that he was treated for his ankles in service, with use of a brace in service. A December 1999 private treatment record indicates right ankle treatment. A March 2007 private treatment record indicate x-rays with a diagnosis of mild arthritis of the ankle and a right ankle sprain. Again, the Board notes that upon examination during his Reserve service in May 1998, the Veteran reported joint pains in general, though without a specific statement as to his bilateral ankles. VA provided a medical examination for the Veteran's bilateral ankle claims in March 2019. The examiner found no diagnosed disability in either ankle. The examiner noted there had been isolated acute ankle issues in December 1999 and again in March 2007, but indicated there was no pathology in either ankle to indicate any chronic disability. The Board finds the March 2019 examination to be highly probative as it is sound and thorough, and had sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting medical literature and clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, there is no diagnosis of a current disability of a bilateral ankle condition by any VA medical examiner. Thus, the Veteran's claim does not meet the first prong of service connection, the requirement of a current disability. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. The Board notes that the existence of a current disability at any time during the current appeal period is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that, at some time during the current appeal period, the Veteran has the disability for which benefits are being claimed. Here, however, as noted above, the competent and credible evidence of record does not establish that, at any time during the current appeal period, the Veteran has had a diagnosis of a bilateral ankles disability. In this regard, the Board notes that Congress has specifically limited service connection to instances where there is current disability (during the current appeal period) that has resulted from disease or injury. 38 U.S.C. § 1110. In the absence of a current disability during the current appeal period, the analysis ends, and the claim for service connection for a bilateral ankle disability cannot be granted. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). Upon review of the evidence of record, the Board finds that the weight of the competent and probative evidence does not demonstrate that entitlement to service connection is warranted for the Veteran's claimed bilateral ankle condition. Here, no examiner or medical professional has made a diagnosis of a current disability related to the Veteran's claimed bilateral ankles. The examination at active service exit in June 1980 indicate no current disability of either a bilateral ankle or related disability. The Board notes the statements from the Veteran regarding his bilateral ankle condition. Generally, lay evidence is probative with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence on its own can be sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. However, a layperson cannot provide evidence as to more complex medical questions and, specifically, cannot provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). To the extent that the Veteran can observe symptoms in his body, to include bilateral ankle, he is competent to comment on and endorse these symptoms. However, the determination of the etiology of a bilateral ankle condition is a complex medical determination beyond his competence. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, the Veteran's statements over time, across three different appeal streams, to include testimony before two different VLJs, indicate at times facial plausibility, internal consistency, consistency with other evidence, and self-interest or bias, which reduces the overall credibility of the Veteran's statements about his disabilities. Accordingly, his assertions to that effect are of no probative value. Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, there is no diagnosis of a current disability of bilateral ankle condition by any VA medical examiner. Thus, the Veteran's claim fails the first prong of service connection, the requirement of a current disability. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Because the Veteran has no in-service or related disease or injury that occurred in service or within one year after leaving active service that is not already accounted for in his other service-connected disabilities, the Veteran fails the second prong of the test for entitlement to direct service connection for his claim of bilateral ankle. See id. The Board has considered the recent holding in Saunders v. Wilkie in which service connection was deemed possible in the absence of a diagnosis when such factors as pain are shown to limit functional ability. Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018) ("pain alone can serve as a functional impairment and therefore qualify as a disability"). That Federal Circuit decision qualified that holding, however: "[w]e do not hold that a veteran could demonstrate service connection simply by asserting subjective pain.... To establish the presence of a disability, the veteran will need to show that [his] pain reaches the level of functional impairment of earning capacity." Id. at 1365. In this case, however, the VA examination conducted during the pendency of this appeal in March 2019 did not show any symptoms of a bilateral ankle disability, to include symptoms of pain for the claim. The Veteran has received an examination for his claimed bilateral ankles, but there has been no observation of symptoms for a bilateral ankle disability. The examiner specifically wrote that no pain was noted on the examination for the bilateral ankles. The examiner determined that any pain, weakness, fatigability, or incoordination did not limit any functional ability. The examiner determined there was insufficient current objective pathology for the claimed bilateral ankle condition, and thus the Veteran does not have a current diagnosis associated with any condition of his bilateral ankles. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed bilateral ankle condition was not incurred in service. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a bilateral ankle condition, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 4. Entitlement to service connection for hemorrhoids Regarding the issue of entitlement to service connection for hemorrhoids, the Veteran asserts that his current hemorrhoid disability is the result of his service. At the January 2017 hearing, the Veteran asserted that his hemorrhoids were present and treated in service, and that his current hemorrhoids continue today, with occurrences once every three months. The Veteran explained his current treatment in detail, to include getting in a tub of water and "pushing it back in." An August 2011 letter from VA Medical Center, written by a nurse practitioner V.D.R., indicates a diagnosis of hemorrhoids and treatment, with an assertion that such diagnosed medical problem has been ongoing since service. However, no rationale or support was provided. The Board notes that a June 1975 service treatment record indicates rectal bleeding, and a December 1986 private treatment record notes a history of hemorrhoids. The Veteran was provided a VA examination in March 2019 for his hemorrhoids claim, and the examiner found no medical objective evidence of a hemorrhoid disability. The Veteran claimed he had been diagnosed with external hemorrhoids in 1974 when he joined the military, and claimed also that after active service in 1979 that he had another out of the disability. The Veteran claimed they recur every two months, last several days, and resolve with a topical cream treatment. The Veteran asserted that he had a colonoscopy in 2006 that resulted in the removal of three polyps. The examiner noted physical inspection was normal with no visible external hemorrhoids. A rectal examination indicated normal sphincter tone, and no internal hemorrhoid condition was found. The examiner concluded there was no pathology to support a current diagnosis of hemorrhoids. The Board finds the March 2019 examination to be highly probative as it is sound and thorough, and had sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting medical literature and clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, there is no diagnosis of a current disability of a hemorrhoids condition by any VA medical examiner. Thus, the Veteran's claim does not meet the first prong of service connection, the requirement of a current disability. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. The Board notes that the existence of a current disability at any time during the current appeal period is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that, at some time during the current appeal period, the Veteran has the disability for which benefits are being claimed. Here, however, as noted above, the competent and credible evidence of record does not establish that, at any time during the current appeal period, the Veteran has had a diagnosis of a hemorrhoids disability. In this regard, the Board notes that Congress has specifically limited service connection to instances where there is current disability (during the current appeal period) that has resulted from disease or injury. 38 U.S.C. § 1110. In the absence of a current disability during the current appeal period, the analysis ends, and the claim for service connection for a hemorrhoids disability cannot be granted. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). Upon review of the evidence of record, the Board finds that the weight of the competent and probative evidence does not demonstrate that entitlement to service connection is warranted for the Veteran's claimed hemorrhoids condition. Here, no examiner or medical professional has made a diagnosis of a current disability related to the Veteran's claimed bilateral ankles. The examination at active service exit in June 1980 indicate no current disability of either a hemorrhoids or related disability. The Board notes the statements from the Veteran regarding his hemorrhoids condition. Generally, lay evidence is probative with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence on its own can be sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. However, a layperson cannot provide evidence as to more complex medical questions and, specifically, cannot provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). To the extent that the Veteran can observe symptoms in his body, to include bilateral ankle, he is competent to comment on and endorse these symptoms. However, the determination of the etiology of a hemorrhoids condition is a complex medical determination beyond his competence. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, the Veteran's statements over time, across three different appeal streams, to include testimony before two different VLJs, indicate at times facial plausibility, internal consistency, consistency with other evidence, and self-interest or bias, which reduces the overall credibility of the Veteran's statements about his disabilities. Accordingly, his assertions to that effect are of no probative value. Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, there is no diagnosis of a current disability of hemorrhoids condition by any VA medical examiner. Thus, the Veteran's claim fails the first prong of service connection, the requirement of a current disability. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Because the Veteran has no in-service or related disease or injury that occurred in service or within one year after leaving active service that is not already accounted for in his other service-connected disabilities, the Veteran fails the second prong of the test for entitlement to direct service connection for his claim of bilateral ankle. See id. The Board has considered the recent holding in Saunders v. Wilkie in which service connection was deemed possible in the absence of a diagnosis when such factors as pain are shown to limit functional ability. Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018) ("pain alone can serve as a functional impairment and therefore qualify as a disability"). That Federal Circuit decision qualified that holding, however: "[w]e do not hold that a veteran could demonstrate service connection simply by asserting subjective pain.... To establish the presence of a disability, the veteran will need to show that [his] pain reaches the level of functional impairment of earning capacity." Id. at 1365. In this case, however, the VA examination conducted during the pendency of this appeal in March 2019 did not show any symptoms of a hemorrhoids disability, to include symptoms of pain for the claim. The Veteran has received an examination for his claimed hemorrhoids, but there has been no observation of symptoms for a hemorrhoids disability. The examiner specifically wrote that no pain was noted on the examination for the hemorrhoids. The examiner determined that any pain, weakness, fatigability, or incoordination did not limit any functional ability. The examiner determined there was insufficient current objective pathology for the claimed hemorrhoids condition, and thus the Veteran does not have a current diagnosis associated with any condition of his hemorrhoids. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed hemorrhoids condition was not incurred in service. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a hemorrhoids condition, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 5. Entitlement to service connection for gastritis At the January 2017 hearing, the Veteran testified that he has current gastritis from service. The Veteran asserts that he was treated for such in service and that he continues to have symptoms but tries to treat it through his diet. A March 1975 service treatment record reports gastritis, and a stomachache in January 1976. A private treatment record from December 1986 indicates complaints of and treatment for gas. A March 2012 private treatment record notes "recent gastroenteritis." The Veteran received a VA examination for his claimed gastritis in March 2019. The VA examiner found no pathology for gastritis and declined to make a diagnosis. The examiner noted an upper endoscopy procedure in 2014, well after the end of the Veteran's active and reserve service, by a private medical facility to treat an H. pylori infection, which was treated with two weeks of antibiotics and was considered resolved. Subsequent medical testing in February 2015 showed that H. pylori infection had resolved with no further symptoms. The examiner did note current complaints of periodic heartburn and acid reflux, occurring about once a week, which the Veteran treats with antiacids. The examiner no history or diagnoses of other stomach-related complaints such as irritable bowel syndrome. Physical examination of the abdominal area was normal, and the examiner indicated the Veteran's current symptoms were indicative of gastroesophageal reflux disease, or GERD, which had no history in the Veteran's service medical records. The Board finds the March 2019 examination to be highly probative as it is sound and thorough, and had sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting medical literature and clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, there is no diagnosis of a current disability of a gastritis condition by any VA medical examiner. Thus, the Veteran's claim does not meet the first prong of service connection, the requirement of a current disability. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. The Board notes that the existence of a current disability at any time during the current appeal period is the cornerstone of a claim for VA disability compensation. 38 U.S.C. § 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997) (holding that sections 1110 and 1131 of the statute as requiring the existence of a present disability for VA compensation purposes cannot be considered arbitrary). Evidence must show that, at some time during the current appeal period, the Veteran has the disability for which benefits are being claimed. Here, however, as noted above, the competent and credible evidence of record does not establish that, at any time during the current appeal period, the Veteran has had a diagnosis of a gastritis disability. In this regard, the Board notes that Congress has specifically limited service connection to instances where there is current disability (during the current appeal period) that has resulted from disease or injury. 38 U.S.C. § 1110. In the absence of a current disability during the current appeal period, the analysis ends, and the claim for service connection for a gastritis disability cannot be granted. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998). Upon review of the evidence of record, the Board finds that the weight of the competent and probative evidence does not demonstrate that entitlement to service connection is warranted for the Veteran's claimed gastritis condition. Here, no examiner or medical professional has made a diagnosis of a current disability related to the Veteran's claimed gastritis. The examination at active service exit in June 1980 indicate no current disability of either a gastritis or related disability. The Board notes the statements from the Veteran regarding his gastritis condition. Generally, lay evidence is probative with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence on its own can be sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. However, a layperson cannot provide evidence as to more complex medical questions and, specifically, cannot provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). To the extent that the Veteran can observe symptoms in his body, to include gastritis, he is competent to comment on and endorse these symptoms. However, the determination of the etiology of a gastritis condition is a complex medical determination beyond his competence. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, the Veteran's statements over time, across three different appeal streams, to include testimony before two different VLJs, indicate at times facial plausibility, internal consistency, consistency with other evidence, and self-interest or bias, which reduces the overall credibility of the Veteran's statements about his disabilities. Accordingly, his assertions to that effect are of no probative value. Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Here, there is no diagnosis of a current disability of gastritis condition by any VA medical examiner. Thus, the Veteran's claim fails the first prong of service connection, the requirement of a current disability. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Because the Veteran has no in-service or related disease or injury that occurred in service or within one year after leaving active service that is not already accounted for in his other service-connected disabilities, the Veteran fails the second prong of the test for entitlement to direct service connection for his claim of gastritis. See id. The Board has considered the recent holding in Saunders v. Wilkie in which service connection was deemed possible in the absence of a diagnosis when such factors as pain are shown to limit functional ability. Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018) ("pain alone can serve as a functional impairment and therefore qualify as a disability"). That Federal Circuit decision qualified that holding, however: "[w]e do not hold that a veteran could demonstrate service connection simply by asserting subjective pain.... To establish the presence of a disability, the veteran will need to show that [his] pain reaches the level of functional impairment of earning capacity." Id. at 1365. In this case, however, the VA examination conducted during the pendency of this appeal in March 2019 did not show any symptoms of a gastritis disability, to include symptoms of pain for the claim. The Veteran has received an examination for his claimed gastritis, but there has been no observation of symptoms for a gastritis disability. The examiner specifically wrote that no pain was noted on the examination for the gastritis. The examiner determined that any pain, weakness, fatigability, or incoordination did not limit any functional ability. The examiner determined there was insufficient current objective pathology for the claimed gastritis condition, and thus the Veteran does not have a current diagnosis associated with any condition of his claimed gastritis. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed gastritis condition was not incurred in service. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a gastritis condition, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 6. Entitlement to service connection for left hip bursitis The Veteran asserts that his bursitis of his bilateral hips, bilateral shoulders, and chest, began in service. The Veteran testified that he had shoulder and chest pain in service, and that his bursitis has moved and spread elsewhere. See January 2017 hearing transcript. A November 1976 service treatment record indicates shoulder pain, and a service treatment record from his National Guard service dated May 1998 indicates bursitis of the Veteran's right hip and upper extremities. Upon examination in May 1998, the Veteran reported joint pains. The Board notes the Veteran is already service-connected for his right hip and a shoulder disability. Private treatment records from 1998 also indicate a diagnosis of bursitis of the right hip and right shoulder, with reports of hip pain. Private treatment records from October 2005 note a diagnosis of bursitis without a notation as to where. The Veteran received a VA examination in March 2019 for his claimed left hip bursitis. The VA examiner made a diagnosis of osteoarthritis of the left hip by x-rays, and noted the Veteran's complaints of periodic, "off and on," left hip pain. The examiner found no evidence of a bursitis condition associated with the trochanter or any other area associated with the left hip. Based on the fact that the Veteran's left hip osteoarthritis was diagnosed 18 years after discharge from military service, and in the absence of any left hip injury or condition diagnosed or recorded in service, the examiner opined negatively for service connection that it was less likely than not, less than 50 percent probability, that the Veteran's degenerative arthritis of each knee was incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted the Veteran's statements about getting medical help after service but there was no evidence of such treatment, or any other treatment from service separation to the examination, a span of 18 years. The Board finds the March 2019 VA examination report and opinion to be of great probative value. Indeed, the examiner considered the Veteran's contention, the claims file, and clinical medical evidence before providing a negative opinion for left hip disability. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The examiner's negative opinion was supported by a sufficiently clear and well-reasoned medical rationale and were consistent with the verifiable facts regarding the Veteran's contentions. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). Upon review of the evidence of record, the Board finds that the weight of the competent and probative evidence does not demonstrate that entitlement to service connection is warranted for the Veteran's claimed left hip bursitis condition. Here, no examiner or medical professional has made a diagnosis of a current disability related to the Veteran's claimed left hip osteoarthritis. The examination at active service exit in June 1980 indicate no current disability of either a left hip or related disability. The Board is cognizant of the right hip complaints in service and subsequent service connection for that disability, but those same records do not denote a left hip condition. The Board notes the statements from the Veteran regarding his left hip condition. Generally, lay evidence is probative with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence on its own can be sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. However, a layperson cannot provide evidence as to more complex medical questions and, specifically, cannot provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). To the extent that the Veteran can observe symptoms in his body, to include gastritis, he is competent to comment on and endorse these symptoms. However, the determination of the etiology of a left hip bursitis condition is a complex medical determination beyond his competence. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, the Veteran's statements over time, across three different appeal streams, to include testimony before two different VLJs, indicate at times facial plausibility, internal consistency, consistency with other evidence, and self-interest or bias, which reduces the overall credibility of the Veteran's statements about his disabilities. Accordingly, his assertions to that effect are of no probative value. Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In addition, the Board finds that the gap in time between the Veteran's last date of active service, in June 1980, or leaving reserve service in 2001, to his initial evaluation by any medical provider regarding his left hip disability in March 2019 to be probative of a lack of nexus between the diagnosed current disability and active service. The Veteran himself noted during his hearing with the undersigned VLJ and in reporting his history to the VA examiner that there were no records of any treatment for any of the disabilities prior to his claim in June 2008, a 7-year gap. A negative inference may be drawn from the absence of complaints or treatment for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board has considered the recent holding in Saunders v. Wilkie in which service connection was deemed possible in the absence of a diagnosis when such factors as pain are shown to limit functional ability. Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018) ("pain alone can serve as a functional impairment and therefore qualify as a disability"). That Federal Circuit decision qualified that holding, however: "[w]e do not hold that a veteran could demonstrate service connection simply by asserting subjective pain.... To establish the presence of a disability, the veteran will need to show that [his] pain reaches the level of functional impairment of earning capacity." Id. at 1365. In this case, however, the VA examination conducted during the pendency of this appeal in March 2019 did not show any chronic symptoms of a left hip disability beyond the diagnosed osteoarthritis, which the examiner considered not to be related to service. The examiner determined that any pain, weakness, fatigability, or incoordination did not limit any functional ability. There are no competent medical opinions of probative value in favor of a positive nexus to active service from any VA examiner or medical treatment provider from any source. Upon review of the record, the Board concludes that entitlement to service connection for a left hip disability is not warranted. The Board notes a current diagnosis of left hip osteoarthritis, and thus the requirement for a current disability is shown. The Board acknowledges the Veteran's contentions, and the Veteran's post-service statements are noted. However, the final physical of June 1980 is silent for any existing left hip bursitis, arthritis, or related injury at the time of separation from active service, and, and there is no competent evidence to tie the current assertions to any in-service disease or injury. The Board thus finds the Veteran fails the third prong of the test for entitlement to direct service connection for the claimed disability. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. With regard to presumptive service connection for degenerative arthritis of the left hip disability, the weight of evidence shows no chronic symptoms of this condition during active service, no continuous symptoms of the condition since service, and that the conditions did not manifest to a compensable degree within one year of service. As such, presumptive service connection is not warranted. 38 C.F.R. §§ 3.303, 3.309. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed left hip disability was not incurred in service. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a left hip disability on a direct or presumptive basis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 7. Entitlement to service connection for foot fungus The Veteran asserts that he has had a right foot and toe disability since his service. At the January 2017 hearing, the Veteran asserted that his current foot condition causes him to have painful and discolored toenails, and asserts that such is from service, to include the showers he took during service. A February 1976 service treatment record indicates toe pain. Private treatment records from August 2001 indicates distorted toenails and private treatment records from May 2005 indicate right foot pain with toenail discomfort due to an infection. A June 2005 private treatment record indicates a diagnosis of onychomycosis. The Veteran received a VA examination in March 2019 for his claimed foot fungus. The VA examiner made a diagnosis of onychomycosis of the feet, and noted the Veteran's complaints of periodic skin irritation and itchiness. Onychomycosis was found in the right first and fifth toenail, and no athlete's foot condition or other foot fungus condition was found on examination. Based on the fact that the Veteran's onychomycosis was diagnosed 18 years after discharge from reserve military service, and in the absence of any foot fungus or related condition diagnosed or recorded in service, the examiner opined negatively for service connection that it was less likely than not, less than 50 percent probability, that the Veteran's onychomycosis was incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted the Veteran's statements about getting medical help after service but there was no evidence of such treatment, or any other treatment from service separation to the examination, a span of 18 years. The Board finds the March 2019 VA examination report and opinion to be of great probative value. Indeed, the examiner considered the Veteran's contention, the claims file, and clinical medical evidence before providing a negative opinion for a foot fungus disability. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The examiner's negative opinion was supported by a sufficiently clear and well-reasoned medical rationale and were consistent with the verifiable facts regarding the Veteran's contentions. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). Upon review of the evidence of record, the Board finds that the weight of the competent and probative evidence does not demonstrate that entitlement to service connection is warranted for the Veteran's claimed foot fungus condition. The examination at active service exit in June 1980 or final reserve service in February 2001 indicate no current disability of either a foot fungus or related disability. The Board notes the statements from the Veteran regarding his foot fungus condition. Generally, lay evidence is probative with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence on its own can be sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. However, a layperson cannot provide evidence as to more complex medical questions and, specifically, cannot provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). To the extent that the Veteran can observe symptoms in his body, to include foot fungus, he is competent to comment on and endorse these symptoms. However, the determination of the etiology of a foot fungus condition is a complex medical determination beyond his competence. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In addition, the Veteran's statements over time, across three different appeal streams, to include testimony before two different VLJs, indicate at times facial plausibility, internal consistency, consistency with other evidence, and self-interest or bias, which reduces the overall credibility of the Veteran's statements about his disabilities. Accordingly, his assertions to that effect are of no probative value. Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). In addition, the Board finds that the gap in time between the Veteran's last date of active service, in June 1980, or leaving reserve service in 2001, to his initial evaluation by any medical provider regarding his foot fungus disability in March 2019 to be probative of a lack of nexus between the diagnosed current disability and active service. The Veteran himself noted during his hearing with the undersigned VLJ and in reporting his history to the VA examiner that there were no records of any treatment for any of the disabilities prior to his claim in June 2008, a 7-year gap. A negative inference may be drawn from the absence of complaints or treatment for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). The Board has considered the recent holding in Saunders v. Wilkie in which service connection was deemed possible in the absence of a diagnosis when such factors as pain are shown to limit functional ability. Saunders v. Wilkie, 886 F.3d 1356, 1364 (Fed. Cir. 2018) ("pain alone can serve as a functional impairment and therefore qualify as a disability"). That Federal Circuit decision qualified that holding, however: "[w]e do not hold that a veteran could demonstrate service connection simply by asserting subjective pain.... To establish the presence of a disability, the veteran will need to show that [his] pain reaches the level of functional impairment of earning capacity." Id. at 1365. In this case, however, the VA examination conducted during the pendency of this appeal in March 2019 did not show any chronic symptoms of a foot fungus disability beyond the diagnosed onychomycosis, which the examiner considered not to be related to service. The examiner determined that any pain, weakness, fatigability, or incoordination did not limit any functional ability. There are no competent medical opinions of probative value in favor of a positive nexus to active service from any VA examiner or medical treatment provider from any source. Upon review of the record, the Board concludes that entitlement to service connection for a foot fungus disability is not warranted. The Board notes a current diagnosis of onychomycosis, and thus the requirement for a current disability is shown. The Board acknowledges the Veteran's contentions, and the Veteran's post-service statements are noted. However, the final physical of June 1980 is silent for any existing foot fungus, onychomycosis, or related injury or condition at the time of separation from active service, and, and there is no competent evidence to tie the current assertions to any in-service disease or injury. The Board thus finds the Veteran fails the third prong of the test for entitlement to direct service connection for the claimed disability. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed foot fungus disability was not incurred in service. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a foot fungus disability on a direct basis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Setter, 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.